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Salazar EG, Passarella M, Formanowski B, Rogowski J, Edwards E, Phibbs C, Lorch SA. The Association of NICU Strain with Neonatal Mortality and Morbidity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.07.07.24310050. [PMID: 39040203 PMCID: PMC11261945 DOI: 10.1101/2024.07.07.24310050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Objective To examine the association of admission NICU strain with neonatal mortality and morbidity. Study Design 2008-2021 South Carolina cohort using linked vital statistics and discharge data of 22-44 weeks GA infants, born at hospitals with ≥ level 2 unit and ≥5 births of infants <34 weeks GA/year. The exposure was tertiles of admission NICU strain, defined as the sum of infants <44 weeks GA with a congenital anomaly plus all infants born <33 weeks GA at midnight on the day of birth. We used Poisson generalized linear mixed models to examine the association of exposure to strain with the primary outcome of a composite of mortality and term and preterm morbidities adjusting for patient and hospital characteristics. Results We studied 64,647 infants from 30 hospitals. High strain was associated with increased risk of mortality and morbidity adjusting for patient/hospital factors (aIRR 1.07, 95% CI 1.01 - 1.12). Conclusion NICU strain is associated with increased adverse outcomes.
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Hadian SA, Rezayatmand R, Shaarbafchizadeh N, Ketabi S, Pourghaderi AR. Hospital performance evaluation indicators: a scoping review. BMC Health Serv Res 2024; 24:561. [PMID: 38693562 PMCID: PMC11064245 DOI: 10.1186/s12913-024-10940-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/02/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Hospitals are the biggest consumers of health system budgets and hence measuring hospital performance by quantitative or qualitative accessible and reliable indicators is crucial. This review aimed to categorize and present a set of indicators for evaluating overall hospital performance. METHODS We conducted a literature search across three databases, i.e., PubMed, Scopus, and Web of Science, using possible keyword combinations. We included studies that explored hospital performance evaluation indicators from different dimensions. RESULTS We included 91 English language studies published in the past 10 years. In total, 1161 indicators were extracted from the included studies. We classified the extracted indicators into 3 categories, 14 subcategories, 21 performance dimensions, and 110 main indicators. Finally, we presented a comprehensive set of indicators with regard to different performance dimensions and classified them based on what they indicate in the production process, i.e., input, process, output, outcome and impact. CONCLUSION The findings provide a comprehensive set of indicators at different levels that can be used for hospital performance evaluation. Future studies can be conducted to validate and apply these indicators in different contexts. It seems that, depending on the specific conditions of each country, an appropriate set of indicators can be selected from this comprehensive list of indicators for use in the performance evaluation of hospitals in different settings.
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Affiliation(s)
- Shirin Alsadat Hadian
- Student Research Committee, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Rezayatmand
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Nasrin Shaarbafchizadeh
- Hospital Management Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Ketabi
- Department of Management, Faculty of Administrative Sciences and Economics, University of Isfahan, Isfahan, Iran
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Gisondo C, Lawrence C, Cham P, Weiner G, Vartanian RJ, Ellsworth L. An Observational Time Study of Neonatal Intensive Care Unit Multidisciplinary Rounds. Am J Perinatol 2024; 41:e689-e693. [PMID: 36041467 DOI: 10.1055/a-1933-7137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE In this observational study, we aimed to describe the rounding structure in a high acuity neonatal intensive care unit (NICU) to identify potential barriers to efficient multidisciplinary rounds. STUDY DESIGN We observed daily medical rounds (January-December 2018) on the resident teaching service in a 46-bed academic level IV NICU. Daily census, duration of rounds, and causes for rounding delays were recorded. During a subset of the study period, additional data were collected describing the time spent on specific activities and the room-to-room pathway followed by the rounding team. Descriptive statistics were used to summarize the census, total rounding time, time spent on each activity, and rounding time by day of the week and by attending. RESULTS A total of 208 rounding days were observed. During the study period, the teaching service mean daily census was 17 patients and total rounding time (mean ± standard deviation) was 136 ± 31 minutes. Mean rounding time and time/patient varied between the nine attendings (total time range 109 minutes to 169 minutes, time/patient range 6.4 minutes/patient to 10.0 minutes/patient). In total, 91% of rounding time focused on patient care, teaching, and discussions with parents, while 9% of the time was spent deciding which patient to see next, moving between rooms, and waiting for members of the team to be ready to start rounds. CONCLUSION On average, the medical team spent over 2 hours per day making multisciplinary rounds in the NICU with substantial variation between attending providers. While most time was spent on patient care, teaching, and talking with parents, we identified opportunities to improve rounding efficiency. KEY POINTS · The structure of rounds in a NICU was observed to identify the potential barriers to efficiency.. · There are limited data on MDR processes in the NICU.. · In total, 9% of time was spent on patient care activities during daily rounds..
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Affiliation(s)
- Carly Gisondo
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Ochsner Baptist-A Campus of Oschner Medical Center, New Orleans, Louisiana
| | - Christin Lawrence
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Beaumont Hospital, Royal Oak, Michigan
| | - Parul Cham
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Gary Weiner
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Rebecca J Vartanian
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Lindsay Ellsworth
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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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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Lapcharoensap W, Bennett M, Xu X, Lee HC, Profit J, Dukhovny D. Quality, outcome, and cost of care provided to very low birth weight infants in California. J Perinatol 2024; 44:224-230. [PMID: 37805592 DOI: 10.1038/s41372-023-01792-4] [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: 01/17/2023] [Revised: 09/21/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE To examine association of costs with quality of care and patient outcome across hospitals in California. METHODS Retrospective study of very low birth weight (VLBW) births from 2014-2018 linking birth certificate, hospital discharge records and clinical data. Quality was measured using the Baby-MONITOR score. Clinical outcome was measured using survival without major morbidity (SWMM). Hierarchical generalized linear models, adjusting for clinical factors, were used to estimate risk-adjusted measures of costs, quality, and outcome for each hospital. Association between these measures was evaluated using Pearson correlation coefficient. RESULTS In total, 15,415 infants from 104 NICUs were included. Risk-adjusted Baby-MONITOR score, SWMM rate, and costs varied substantially. There was no correlation between risk-adjusted cost and Baby-MONITOR score (r = 0, p = 0.998). Correlation between risk-adjusted cost and SWMM rate was inverse and not significant (r = -0.07, p = 0.48). CONCLUSIONS With the metrics used, we found no correlation between cost, quality, and outcomes in the care of VLBW infants.
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Affiliation(s)
- Wannasiri Lapcharoensap
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, 97239, USA.
| | - Mihoko Bennett
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, 94305, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, 94305, USA
| | - Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT, 06520, USA
| | - Henry C Lee
- California Perinatal Quality Care Collaborative, Stanford, CA, 94305, USA
- Division of Neonatology, Department of Pediatrics, University of California San Diego, La Jolla, CA, 92093, USA
| | - Jochen Profit
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, 94305, USA
- California Perinatal Quality Care Collaborative, Stanford, CA, 94305, USA
| | - Dmitry Dukhovny
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, 97239, USA
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Salazar EG, Handley SC, Greenberg LT, Edwards EM, Lorch SA. Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants. JAMA Pediatr 2023; 177:278-285. [PMID: 36648939 PMCID: PMC9857785 DOI: 10.1001/jamapediatrics.2022.5213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023]
Abstract
Importance A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown. Objective To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants. Design, Setting, and Participants This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database. Exposures NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs). Main Outcomes and Measures The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type. Results Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score. Conclusions and Relevance In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.
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Affiliation(s)
- Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Lucy T. Greenberg
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Mathematics and Statistics, The University of Vermont, Burlington
- Department of Pediatrics, The Robert Larner, MD College of Medicine, The University of Vermont, Burlington
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Bourque SL, Weikel BW, Crispe K, Hwang SS. Association of Rural and Frontier Residence with Very Preterm and Very Low Birth Weight Delivery in Nonlevel III NICUs. Am J Perinatol 2023; 40:35-41. [PMID: 33878765 DOI: 10.1055/s-0041-1727222] [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] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Delivery of very preterm and very low birth weight neonates (VPT/VLBW) in a nonlevel III neonatal intensive care unit (NICU) increases risk of morbidity and mortality. Study objectives included the following: (1) Determine incidence of VPT/VLBW delivery (<32 weeks gestational age and/or birth weight <1,500 g), in nonlevel III units in Colorado; (2) Evaluate the independent association between residence and nonlevel III unit delivery; (3) Determine the incidence of and factors associated with postnatal transfer. STUDY DESIGN This retrospective cohort study used 2007 to 2016 Colorado birth certificate data. Demographic and clinical characteristics by VPT/VLBW delivery in level III NICUs versus nonlevel III units were compared using Chi-square analyses. Multivariable logistic regression was used to estimate the independent association between residence and VPT/VLBW delivery. RESULTS Among patients, 897 of 10,015 (8.96%) VPT/VLBW births occurred in nonlevel III units. Compared with infants born to pregnant persons in urban counties, infants born to those residing in rural (adjusted odds ratio [AOR] = 1.58, 95% confidence interval [CI]: 1.33, 1.88) or frontier (AOR = 3.19, 95% CI: 2.14, 4.75) counties were more likely to deliver in nonlevel III units and to experience postnatal transfer within 24 hours (rural AOR = 2.24, 95% CI: 1.60, 3.15; frontier AOR = 3.91, 95% CI: 1.76, 8.67). Compared with non-Hispanic Whites, Hispanics were more likely to deliver VPT/VLBW infants in nonlevel III units (AOR = 1.36, 95% CI: 1.15, 1.61). CONCLUSION A significant number of VPT/VLBW neonates were born in nonlevel III units with associated disparities by race/ethnicity and nonurban residence. KEY POINTS · Preterm delivery in a nonlevel III NICU increases risk of neonatal morbidity and mortality.. · A significant number of preterm deliveries in Colorado occur in hospitals with nonlevel III NICUs.. · Disparities in preterm delivery by race/ethnicity and nonurban residence exist..
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Affiliation(s)
- Stephanie L Bourque
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Blair W Weikel
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
| | - Kristin Crispe
- Department of Family Medicine, University of Colorado, Aurora, Colorado
| | - Sunah S Hwang
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Aurora, Colorado
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Measuring quality of care in moderate and late preterm infants. J Perinatol 2022; 42:1294-1300. [PMID: 35354940 PMCID: PMC9522891 DOI: 10.1038/s41372-022-01377-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/22/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine quality measures for moderate and late preterm (MLP) infants. STUDY DESIGN By prospectively analyzing Vermont Oxford Network's all NICU admissions database, we adapted Baby-MONITOR, a composite quality measure for extremely/very preterm infants, for MLP infants. We examined correlations between the adapted MLP quality measure (MLP-QM) in MLP infants and Baby-MONITOR in extremely and very preterm infants. RESULT We studied 376,219 MLP (30-36 weeks GA) and 57,595 extremely/very preterm (25-29 weeks GA) infants from 465 U.S. hospitals born from 2016 to 2020. MLP-QM summary scores in MLP infants had weak correlation with Baby-MONITOR scores in extremely and very preterm infants (r = 0.47). There was weak correlation among survival (r = 0.19), no pneumothorax (r = 0.35), and no infection after 3 days (r = 0.45), but strong correlation among human milk at discharge (r = 0.79) and no hypothermia (r = 0.76). CONCLUSION Modest correlation among hospital care measures in two preterm populations suggests the need for MLP-specific care measures.
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Ondusko DS, Garg B, Caughey AB, Pilliod RA, Carter EH. Is Appropriate Administration of Antenatal Corticosteroids Associated with Maternal Race? Am J Perinatol 2022; 39:1204-1211. [PMID: 33374022 DOI: 10.1055/s-0040-1721717] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Antenatal corticosteroids (ACSs) improve outcomes for premature infants; however, not all pregnant women at risk for preterm delivery receive ACS. Racial minorities are less likely to receive adequate prenatal care and more likely to deliver preterm. The objective of this study was to determine if maternal race is associated with a lower rate of ACS administration in Washington for women at risk of preterm labor (between 23 and 34 weeks). STUDY DESIGN This was a population-based retrospective cohort study of singleton, nonanomalous, premature deliveries in Washington state between 2007 and 2014. Descriptive data included maternal sociodemographics, pregnancy complications, facility of birth, and neonatal characteristics. The primary outcome was maternal receipt of ACS and the independent variable was maternal race/ethnicity. The secondary outcomes included neonatal need for assisted ventilation, both initially and for more than 6 hours, and administration of surfactant. Data were analyzed using chi-square tests and logistic regression models. RESULTS A total of 8,530 nonanomalous, singleton neonates were born between 23 and 34 weeks' gestation. Of those, 55.8% of mothers were self-identified as white, 7.5% as black, 21.4% as Hispanic, 10.9% as Asian, and 4.3% as Native American. After adjusting for confounders, black woman-neonate dyads had significantly lower odds of receiving ACS, (adjusted odds ratio [aOR] = 0.62; 95% confidence interval [CI]: 0.51-0.76), assisted ventilation immediately following delivery (aOR = 0.76; 95% CI: 0.61-0.94) and for more than 6 hours (aOR = 0.64; 95% CI: 0.49-0.84) and surfactant therapy (aOR = 0.62; 95% CI: 0.42-0.92) as compared with whites. CONCLUSION These findings contribute to the current body of literature by describing racial disparities in ACS administration for pregnant women at risk for preterm delivery. To better understand the association between black race and administration of ACS, future studies should focus on differences within and between hospitals (including quality, location, resources), patient health literacy, social determinants of health, and exposure to systemic racism and discrimination. KEY POINTS · Black women were less likely to receive antenatal steroids.. · Black neonates had lower odds of respiratory support.. · Black neonates had lower odds of receiving surfactant..
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Affiliation(s)
- Devlynne S Ondusko
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Bharti Garg
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Rachel A Pilliod
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Emily H Carter
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
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Liu J, Pang EM, Iacob A, Simonian A, Phibbs CS, Profit J. Evaluating Care in Safety Net Hospitals: Clinical Outcomes and Neonatal Intensive Care Unit Quality of Care in California. J Pediatr 2022; 243:99-106.e3. [PMID: 34890584 PMCID: PMC8960349 DOI: 10.1016/j.jpeds.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/22/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To examine the characteristics of safety net (sn) and non-sn neonatal intensive care units (NICUs) in California and evaluate whether the site of care is associated with clinical outcomes. STUDY DESIGN This population-based retrospective cohort study of 34 snNICUs and 104 non-snNICUs included 22 081 infants born between 2014 and 2018 with a birth weight of 401-1500 g or gestational age of 22-29 weeks. Quality of care as measured by the Baby-MONITOR score and rates of survival without major morbidity were compared between snNICUs and non-snNICUs. RESULTS Black and Hispanic infants were cared for disproportionately in snNICUs, where care and outcomes varied widely. We found no significant differences in Baby-Measure Of Neonatal InTensive care Outcomes Research (MONITOR) scores (z-score [SD]: snNICUs, -0.31 [1.3]; non-snNICUs, 0.03 [1.1]; P = .1). Among individual components, infants in snNICUs exhibited lower rates of human milk nutrition at discharge (-0.64 [1.0] vs 0.27 [0.9]), lower rates of no health care-associated infection (-0.27 [1.1] vs 0.14 [0.9]), and higher rates of no hypothermia on admission (0.39 [0.7] vs -0.25 [1.1]). We found small but significant differences in survival without major morbidity (adjusted rate, 65.9% [95% CI, 63.9%-67.9%] for snNICUs vs 68.3% [95% CI, 67.0%-69.6%] for non-snNICUs; P = .02) and in some of its components; snNICUs had higher rates of necrotizing enterocolitis (3.8% [3.4%-4.3%] vs 3.1% [95% CI, 2.8%-3.4%]) and mortality (95% CI, 7.1% [6.5%-7.7%] vs 6.6% [6.2%-7.0%]). CONCLUSIONS snNICUs achieved similar performance as non-snNICUs in quality of care except for small but significant differences in any human milk at discharge, infection, hypothermia, necrotizing enterocolitis, and mortality.
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Affiliation(s)
- Jessica Liu
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Emily M Pang
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
| | - Alexandra Iacob
- California Perinatal Quality Care Collaborative, Palo Alto, CA; Division of Neonatal/Perinatal Medicine, Department of Pediatrics, School of Medicine, University of California Irvine, Orange, CA
| | - Aida Simonian
- California Perinatal Quality Care Collaborative, Palo Alto, CA
| | - Ciaran S Phibbs
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Healthcare System, Menlo Park, CA
| | - Jochen Profit
- Division of Neonatology, Department of Pediatrics, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA; California Perinatal Quality Care Collaborative, Palo Alto, CA.
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11
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End-of-Life Decision-Making in Pediatric and Neonatal Intensive Care Units in Croatia—A Focus Group Study among Nurses and Physicians. Medicina (B Aires) 2022; 58:medicina58020250. [PMID: 35208575 PMCID: PMC8879945 DOI: 10.3390/medicina58020250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Objectives: Working in pediatric and neonatal intensive care units (ICUs) can be challenging and differs from work in adult ICUs. This study investigated for the first time the perceptions, experiences and challenges that healthcare professionals face when dealing with end-of-life decisions in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) in Croatia. Materials and Methods: This qualitative study with focus groups was conducted among physicians and nurses working in NICUs and PICUs in five healthcare institutions (three pediatric intensive care units (PICUs) and five neonatal intensive care units (NICUs)) at the tertiary level of healthcare in the Republic of Croatia, in Zagreb, Rijeka and Split. A total of 20 physicians and 21 nurses participated in eight focus groups. The questions concerned everyday practices in end-of-life decision-making and their connection with interpersonal relationships between physicians, nurses, patients and their families. The constant comparative analysis method was used in the analysis of the data. Results: The analysis revealed two main themes that were the same among the professional groups as well as in both NICU and PICU units. The theme “critical illness” consisted of the following subthemes: the child, the family, myself and other professionals. The theme “end-of-life procedures” consisted of the following subthemes: breaking point, decision-making, end-of-life procedures, “spill-over” and the four walls of the ICU. The perceptions and experiences of end-of-life issues among nurses and physicians working in NICUs and PICUs share multiple common characteristics. The high variability in end-of-life procedures applied and various difficulties experienced during shared decision-making processes were observed. Conclusions: There is a need for further research in order to develop clinical and professional guidelines that will inform end-of-life decision-making, including the specific perspectives of everyone involved, and the need to influence policymakers.
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Kunz SN, Helkey D, Zitnik M, Phibbs CS, Rigdon J, Zupancic JAF, Profit J. Quantifying the variation in neonatal transport referral patterns using network analysis. J Perinatol 2021; 41:2795-2803. [PMID: 34035453 PMCID: PMC8613294 DOI: 10.1038/s41372-021-01091-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/31/2021] [Accepted: 04/30/2021] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Regionalized care reduces neonatal morbidity and mortality. This study evaluated the association of patient characteristics with quantitative differences in neonatal transport networks. STUDY DESIGN We retrospectively analyzed prospectively collected data for infants <28 days of age acutely transported within California from 2008 to 2012. We generated graphs representing bidirectional transfers between hospitals, stratified by patient attribute, and compared standard network analysis metrics. RESULT We analyzed 34,708 acute transfers, representing 1594 unique transfer routes between 271 hospitals. Density, centralization, efficiency, and modularity differed significantly among networks drawn based on different infant attributes. Compared to term infants and to those transported for medical reasons, network metrics identify greater degrees of regionalization for preterm and surgical patients (more centralized and less dense, respectively [p < 0.001]). CONCLUSION Neonatal interhospital transport networks differ by patient attributes as reflected by differences in network metrics, suggesting that regionalization should be considered in the context of a multidimensional system.
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Affiliation(s)
- Sarah N. Kunz
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Daniel Helkey
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,California Perinatal Quality Care Collaborative, Palo Alto, California, USA
| | - Marinka Zitnik
- Department of Biomedical Informatics, Harvard University, Boston, Massachusetts, USA
| | - Ciaran S. Phibbs
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,Health Economics Resource Center, Veterans Affairs Palo Alto Healthcare Systm, Menlo Park, California, USA
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - John A. F. Zupancic
- Division of Newborn Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jochen Profit
- Department of Pediatrics – Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, California, USA,California Perinatal Quality Care Collaborative, Palo Alto, California, USA
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13
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Handley SC, Passarella M, Herrick HM, Interrante JD, Lorch SA, Kozhimannil KB, Phibbs CS, Foglia EE. Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018. JAMA Netw Open 2021; 4:e2125373. [PMID: 34623408 PMCID: PMC8501399 DOI: 10.1001/jamanetworkopen.2021.25373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care. OBJECTIVE To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume. DESIGN, SETTING, AND PARTICIPANTS This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021. EXPOSURE Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births. MAIN OUTCOMES AND MEASURES Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area. RESULTS The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas. CONCLUSIONS AND RELEVANCE In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.
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Affiliation(s)
- Sara C. Handley
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Molly Passarella
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heidi M. Herrick
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia D. Interrante
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Scott A. Lorch
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, The University of Pennsylvania, Philadelphia
| | - Katy B. Kozhimannil
- Division of Health Policy & Management, University of Minnesota School of Public Health, Minneapolis
| | - Ciaran S. Phibbs
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
- Stanford University School of Medicine, Stanford, California
| | - Elizabeth E. Foglia
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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14
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Edwards EM, Greenberg LT, Profit J, Draper D, Helkey D, Horbar JD. Quality of Care in US NICUs by Race and Ethnicity. Pediatrics 2021; 148:e2020037622. [PMID: 34301773 PMCID: PMC8344358 DOI: 10.1542/peds.2020-037622] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Summary measures are used to quantify a hospital's quality of care by combining multiple metrics into a single score. We used Baby-MONITOR, a summary quality measure for NICUs, to evaluate quality by race and ethnicity across and within NICUs in the United States. METHODS Vermont Oxford Network members contributed data from 2015 to 2019 on infants from 25 to 29 weeks' gestation or of 401 to 1500 g birth weight who were inborn or transferred to the reporting hospital within 28 days of birth. Nine Baby-MONITOR measures were individually risk adjusted, standardized, equally weighted, and averaged to derive scores for African American, Hispanic, Asian American, and American Indian infants, compared with white infants. RESULTS This prospective cohort included 169 400 infants at 737 hospitals. Across NICUs, Hispanic and Asian American infants had higher Baby-MONITOR summary scores, compared with those of white infants. African American and American Indian infants scored lower on process measures, and all 4 minority groups scored higher on outcome measures. Within NICUs, the mean summary scores for African American, Hispanic, and Asian American NICU subsets were higher, compared with those of white infants in the same NICU. American Indian summary NICU scores were not different, on average. CONCLUSIONS With Baby-MONITOR, we identified differences in NICU quality by race and ethnicity. However, the summary score masked within-measure quality gaps that raise unanswered questions about the relationships between race and ethnicity and processes and outcomes of care.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD College of Medicine
- Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont
| | | | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - David Draper
- Department of Statistics, Jack Baskin School of Engineering, University of California, Santa Cruz, Santa Cruz, California
| | - Daniel Helkey
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, Vermont
- Department of Pediatrics, Robert Larner, MD College of Medicine
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15
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Tay CC, de la O S, Finn S, Fritzell J. More than Just a Fad: Building and Maintaining a Small Baby Program. Neonatal Netw 2021; 40:224-232. [PMID: 34330872 DOI: 10.1891/11-t-716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2021] [Indexed: 11/25/2022]
Abstract
Survival rate for preterm infants has improved significantly in the last decade because of advancements in care provided by NICUs. Yet, a large proportion of extremely low birth weight (ELBW) infants continue to be at risk of being discharged home from NICUs with long-term co-morbidities. Several centers have introduced and described the concept of a focused program on the care of micro-preemies and demonstrated improved processes as well as outcomes utilizing a continuous improvement approach with adoption of standardized guidelines, checklists, and shared team values. The journey and effort that it takes to develop and sustain such a program have been described less. This article discusses the process of building a Small Baby Program using a change model framework, how the organization and staff bought into the concept, as well as the accomplishments and challenges experienced during the last 3 years as the program continues to evolve and grow.
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16
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Lorch SA, Rogowski J, Profit J, Phibbs CS. Access to risk-appropriate hospital care and disparities in neonatal outcomes in racial/ethnic groups and rural-urban populations. Semin Perinatol 2021; 45:151409. [PMID: 33931237 PMCID: PMC8184635 DOI: 10.1016/j.semperi.2021.151409] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Variations in infant and neonatal mortality continue to persist in the United States and in other countries based on both socio-demographic characteristics, such as race and ethnicity, and geographic location. One potential driver of these differences is variations in access to risk-appropriate delivery care. The purpose of this article is to present the importance of delivery hospitals on neonatal outcomes, discuss variation in access to these hospitals for high-risk infants and their mothers, and to provide insight into drivers for differences in access to high-quality perinatal care using the available literature. This review also illustrates the lack of information on a number of topics that are crucial to the development of evidence-based interventions to improve access to appropriate delivery hospital services and thus optimize the outcomes of high-risk mothers and their newborns.
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Affiliation(s)
- Scott A. Lorch
- Children's Hospital of Philadelphia, Division of Neonatology,Perelman School of Medicine, University of Pennsylvania
| | | | - Jochen Profit
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine
| | - Ciaran S. Phibbs
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal Medicine,Veterans Affairs Palo Alto Health Care System
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17
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Padula AM, Shariff-Marco S, Yang J, Jain J, Liu J, Conroy SM, Carmichael SL, Gomez SL, Phibbs C, Oehlert J, Gould JB, Profit J. Multilevel social factors and NICU quality of care in California. J Perinatol 2021; 41:404-412. [PMID: 32157221 PMCID: PMC7483231 DOI: 10.1038/s41372-020-0647-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 02/21/2020] [Accepted: 02/27/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Our objective was to incorporate social and built environment factors into a compendium of multilevel factors among a cohort of very low birth weight infants to understand their contributions to inequities in NICU quality of care and support providers and NICUs in addressing these inequities via development of a health equity dashboard. STUDY DESIGN We examined bivariate associations between NICU patient pool and NICU catchment area characteristics and NICU quality of care with data from a cohort of 15,901 infants from 119 NICUs in California, born 2008-2011. RESULT NICUs with higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. NICUs with catchment areas of lower SES, higher composition of minority residents, and more household crowding had lower quality scores. CONCLUSION Multilevel social factors impact quality of care in the NICU. Their incorporation into a health equity dashboard can inform providers of their patients' potential resource needs.
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Affiliation(s)
- Amy M Padula
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Salma Shariff-Marco
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Juan Yang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jennifer Jain
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Jessica Liu
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Shannon M Conroy
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Scarlett L Gomez
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Ciaran Phibbs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - John Oehlert
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeffrey B Gould
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jochen Profit
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
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18
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Atun R, Bhakta N, Denburg A, Frazier AL, Friedrich P, Gupta S, Lam CG, Ward ZJ, Yeh JM, Allemani C, Coleman MP, Di Carlo V, Loucaides E, Fitchett E, Girardi F, Horton SE, Bray F, Steliarova-Foucher E, Sullivan R, Aitken JF, Banavali S, Binagwaho A, Alcasabas P, Antillon F, Arora RS, Barr RD, Bouffet E, Challinor J, Fuentes-Alabi S, Gross T, Hagander L, Hoffman RI, Herrera C, Kutluk T, Marcus KJ, Moreira C, Pritchard-Jones K, Ramirez O, Renner L, Robison LL, Shalkow J, Sung L, Yeoh A, Rodriguez-Galindo C. Sustainable care for children with cancer: a Lancet Oncology Commission. Lancet Oncol 2020; 21:e185-e224. [PMID: 32240612 DOI: 10.1016/s1470-2045(20)30022-x] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 11/22/2019] [Accepted: 01/14/2020] [Indexed: 12/29/2022]
Abstract
We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.
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Affiliation(s)
- Rifat Atun
- Department of Global health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston MA, USA.
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Avram Denburg
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - A Lindsay Frazier
- Dana-Farber and Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Sumit Gupta
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Catherine G Lam
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Zachary J Ward
- Center for Health Decision Science, Harvard T H Chan School of Public Health, Harvard University, Boston MA, USA
| | - Jennifer M Yeh
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston MA, USA; Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Claudia Allemani
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Michel P Coleman
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Veronica Di Carlo
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Elizabeth Fitchett
- University College London Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Fabio Girardi
- Cancer Survival Group, Department of Non-communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan E Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Freddie Bray
- Section of Cancer Surveillance, International Agency for Research on Cancer, WHO, Lyon, France
| | - Eva Steliarova-Foucher
- Section of Cancer Surveillance, International Agency for Research on Cancer, WHO, Lyon, France
| | - Richard Sullivan
- Institute of Cancer Policy, Conflict and Health Research Group, School of Cancer Sciences, King's College London, London, UK
| | - Joanne F Aitken
- Cancer Council Queensland, Brisbane, QLD, Australia; School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Shripad Banavali
- Department of Medical and Pediatric Oncology, Tata Memorial Center, Mumbai, India; Homi Bhabha National Institute, Mumbai, India
| | | | - Patricia Alcasabas
- Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Federico Antillon
- Unidad Nacional de Oncología Pediátrica and the School of Medicine, Universidad Francisco Marroquín, Guatemala City, Guatemala
| | - Ramandeep S Arora
- Department of Medical Oncology, Max Super-Specialty Hospital, New Delhi, India
| | - Ronald D Barr
- Departments of Pediatrics, Pathology and Medicine, Michael G DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Eric Bouffet
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Julia Challinor
- School of Nursing, University of California San Francisco, San Francisco, CA, USA
| | | | - Thomas Gross
- Center for Global Health, US National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lars Hagander
- Department of Clinical Sciences Lund, Pediatric Surgery, WHO Collaborating Centre for Surgery and Public Health, Lund University Faculty of Medicine, Lund, Sweden
| | - Ruth I Hoffman
- American Childhood Cancer Organization, Beltsville, MD, USA
| | - Cristian Herrera
- Health Division, Organization for Economic Cooperation and Development, Paris, France; Department of Public Health, Faculty of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Tezer Kutluk
- Department of Pediatrics, Division of Pediatric Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey; Cancer Institute, Hacettepe University, Ankara, Turkey
| | - Karen J Marcus
- Department of Radiation Oncology, Harvard Medical School, Harvard University, Boston MA, USA; Division of Radiation Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Claude Moreira
- Institut Jean Lemerle, African Paediatric Oncology Formation, Dakar, Senegal; Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Senegal
| | - Kathy Pritchard-Jones
- University College London Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Oscar Ramirez
- Department of Pediatric Haematology and Oncology, Centro Médico Imbanaco de Cali, Cali, Colombia; Cali Cancer Population-based Registry, Universidad del Valle, Cali, Colombia
| | - Lorna Renner
- Department of Child Health, University of Ghana Medical School Accra, Ghana; Paediatric Oncology Unit, Korle Bu Teaching Hospital, Accra, Ghana
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Jaime Shalkow
- Department of Pediatric Surgical Oncology, National Institute of Pediatrics, Mexico City, Mexico; School of Medicine, Anahuac University, Mexico City, Mexico
| | - Lillian Sung
- Division of Haematology and Oncology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Allen Yeoh
- Division of Paediatric Haematology and Oncology, National University Cancer Institute, Singapore National University Health System, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA.
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Abstract
OBJECTIVES This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals. STUDY DESIGN This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative. RESULTS Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection. CONCLUSION Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.
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Affiliation(s)
- Jessica Liu
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Charlotte Sakarovitch
- Division of Biomedical Informatics Research, Department of Medicine, Stanford University, Stanford, California
- Medical Data Lab, Université Côte d’Azur, Nice, France
| | - Krista Sigurdson
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Henry C. Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University School of Medicine, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
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Tawfik DS, Profit J, Lake ET, Liu JB, Sanders LM, Phibbs CS. Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit. Health Serv Res 2019; 55:190-200. [PMID: 31869865 DOI: 10.1111/1475-6773.13249] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Daniel S Tawfik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Jochen Profit
- California Perinatal Quality Care Collaborative, Palo Alto, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Eileen T Lake
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Jessica B Liu
- California Perinatal Quality Care Collaborative, Palo Alto, California.,Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Lee M Sanders
- Division of General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Ciaran S Phibbs
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California.,Health Economics Research Center and Center for Innovation to Implementation, Veteran's Affairs Palo Alto Health Care System, Palo Alto, California
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21
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Abstract
BACKGROUND The role of the neonatal nurse practitioner (NNP) is well established in the neonatal intensive care unit. The level IV NNP is traditionally supported by large multidisciplinary teams while the level I to III NNP may be the sole in-house provider with limited resources. PURPOSE The purpose of this research project is to identify the NNP role, responsibilities, and barriers to practice in the level I, II, and III newborn care settings. METHODS This study used a descriptive, exploratory design to examine NNP roles and responsibilities in level I, II, and III care centers via an online survey. RESULTS Of the respondents (171), the majority (71.3%) work 24-hour shifts, 51.5% being the single NNP during the day with 67.8% being alone at night. Nearly 27% have limited or are without ancillary support while 29.8% cannot meet some standards of care due to inadequate resources. Almost 22% lack written protocols and procedural opportunities are limited or a concern for 15.8% of the NNPs. IMPLICATIONS FOR PRACTICE A better understanding of the responsibilities of the level I to III NNP will assist with developing staffing guidelines, influence practice models, and guide recruitment and retention of the NNP. IMPLICATIONS FOR RESEARCH A systematic literature review yielded articles on the value of nurse practitioners and their ability to deliver safe, effective and cost-conscience care but not on what the role entails on a daily basis. Further studies are needed to specifically compare the role of the level IV NNP to the level I, II, and III NNP to further delineate NNP functionality according to level of care.
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Kaempf JW, Wang L, Dunn M. Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units. Arch Dis Child Fetal Neonatal Ed 2019; 104:F13-F17. [PMID: 29298857 DOI: 10.1136/archdischild-2017-313715] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/17/2017] [Accepted: 11/27/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Continuous quality improvement (CQI) collaboration has not eliminated the morbidity variability seen among neonatal intensive care units (NICUs). Factors other than inconstant application of potentially better practices (PBPs) might explain divergent proficiency. OBJECTIVE Measure a composite morbidity score and determine whether cultural, environmental and cognitive factors distinguish high proficiency from lower proficiency NICUs. DESIGN/METHODS Retrospective analysis using a risk-adjusted composite morbidity score (Benefit Metric) and cultural survey focusing on very low birth weight (VLBW) infants from 39 NICUs, years 2000-2014. The Benefit Metric and yearly variance from the group mean was rank-ordered by NICU. A comprehensive survey was completed by each NICU exploring whether morbidity variance correlated with CQI methodology, cultural, environmental and/or cognitive characteristics. RESULTS 58 272 VLBW infants were included, mean (SD) age 28.2 (3.0) weeks, birth weight 1031 (301) g. The 39 NICU groups' Benefit Metric improved 40%, from 80 in 2000 to 112 in 2014 (P<0.001). 14 NICUs had composite morbidity scores significantly better than the group, 16 did not differ and 9 scored below the group mean. The 14 highest performing NICUs were characterised by more effective team work, superior morale, greater problem-solving expectations of providers, enhanced learning opportunities, knowledge of CQI fundamentals and more generous staffing. CONCLUSION Cultural, environmental and cognitive characteristics vary among NICUs perhaps more than traditional CQI methodology and PBPs, possibly explaining the inconstancy of VLBW infant morbidity reduction efforts. High proficiency NICUs foster spirited team work and camaraderie, sustained learning opportunities and support of favourable staffing that allows problem solving and widespread involvement in CQI activities.
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Affiliation(s)
- Joseph W Kaempf
- Women and Children's Services, Department of Neonatology, Providence Health System, St. Vincent Medical Center, Medical Data and Research Center, Portland, Oregon, USA
| | - Lian Wang
- Women and Children's Services, Department of Neonatology, Providence Health System, St. Vincent Medical Center, Medical Data and Research Center, Portland, Oregon, USA
| | - Michael Dunn
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Aboudi D, Shah SI, La Gamma EF, Brumberg HL. Impact of neonatologist availability on preterm survival without morbidities. J Perinatol 2018; 38:1009-1016. [PMID: 29743659 DOI: 10.1038/s41372-018-0103-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 02/09/2018] [Accepted: 02/21/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We assessed birth hospital level and neonatal outcomes within a model of regionalization featuring neonatologists at all levels of care, including well-baby nurseries without an accompanying neonatal intensive care unit. METHODS Data were analyzed by NY State adaptation of American Academy of Pediatrics defined levels of care; n = 998, 23-30 weeks gestational age, 400-1250 g birth weight, and admitted to the regional center (2006-2015). Primary outcomes were survival, neurologic survival, and intact survival. RESULTS Level III hospitals transferred 82% of neonates ≥24 h of life compared to ≤2% at Level I or II hospitals (p < 0.05). Primary outcomes were equivalent for Levels I vs. II born neonates with similar postnatal age at transfer and similar to inborn rates (Levels I and II vs. IV). CONCLUSIONS When transferred within 24 h, Levels I or II born infants had equivalent outcomes to inborn Level IV infants in a model of neonatologist availability at all deliveries.
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Affiliation(s)
- David Aboudi
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Shetal I Shah
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Edmund F La Gamma
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA
| | - Heather L Brumberg
- Department of Pediatrics, Division of Newborn Medicine, Maria Fareri Children's Hospital at Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA.
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24
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Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care. J Perinatol 2018; 38:751-758. [PMID: 29593356 DOI: 10.1038/s41372-018-0092-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 02/14/2018] [Accepted: 02/20/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To identify key features in the NICU care delivery context that influence quality of care delivery. STUDY DESIGN Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory. RESULTS Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital. CONCLUSIONS Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.
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Miedaner F, Langhammer K, Enke C, Göpel W, Kribs A, Nitzsche A, Riedel R, Woopen C, Kuntz L, Roth B. Volume, size, professionals' specialization and nutrition management of NICUs and their association with treatment quality in VLBW infants. J Perinatol 2018; 38:402-410. [PMID: 29371627 DOI: 10.1038/s41372-017-0036-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/02/2017] [Accepted: 11/16/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the association of volume, size, the availability of highly-specialized professionals and nutrition management of NICUs with treatment quality among VLBW infants. STUDY DESIGN A prospective multicenter study of 923 VLBW infants in 66 German NICUs, born between May and October 2013. Using multilevel modeling, we examined the association between the aforementioned organizational characteristics and treatment quality, measured via major morbidities (severe IVH, PVL, BPD, NEC, FIP, ROP, and discharge without severe complications) and medical process measures of VLBW infants. RESULTS After risk-adjustment and accounting for other NICU characteristics, infants in low-volume NICUs were at higher risk of IVH, ROP and PVL. However, the initial effect of volume on process measures (growth velocity, administration of antenatal steroids) disappeared. CONCLUSION Volume can only partially explain differences in the treatment quality of VLBWs. The underlying organizational mechanisms should be considered to improve the quality of care.
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Affiliation(s)
- Felix Miedaner
- Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany.
| | - Kristina Langhammer
- Department of Neonatology and Pediatric Intensive Care, University Hospital of Cologne, Cologne, Germany
| | - Christian Enke
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres) and Research Unit Ethics, Medical Faculty, University Clinic Cologne, Cologne, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Angela Kribs
- Department of Neonatology and Pediatric Intensive Care, University Hospital of Cologne, Cologne, Germany
| | - Anika Nitzsche
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Rainer Riedel
- Institute for Medical Economics and Health Services Research, Rheinische Fachhochschule Cologne, Cologne, Germany
| | - Christiane Woopen
- Cologne Center for Ethics, Rights, Economics, and Social Sciences of Health (ceres) and Research Unit Ethics, Medical Faculty, University Clinic Cologne, Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany
| | - Bernhard Roth
- Department of Neonatology and Pediatric Intensive Care and Department of Business Administration and Healthcare Management, University of Cologne, Cologne, Germany
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26
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Comparison of state risk-appropriate neonatal care policies with the 2012 AAP policy statement. J Perinatol 2018; 38:411-420. [PMID: 29209032 PMCID: PMC5955781 DOI: 10.1038/s41372-017-0006-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 10/12/2017] [Accepted: 10/17/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Compare state policies with standards outlined in the 2012 AAP Policy Statement on Levels of Neonatal Care. STUDY DESIGN Systematic, web-based review of publicly available policies on levels of care in all states in 2014. Infant risk information, equipment capabilities, and specialty staffing were abstracted from published rules, statutes, and regulations. RESULT Twenty-two states had a policy on regionalized perinatal care. State policies vary in consistency with the AAP Policy, with 60% of states including standards consistent with Level I criteria, 48% Level II, 14% Level III, and one state with Level IV. Ventilation capability standards are highly consistent (66-100%), followed by imaging capability standards (50-90%). Policy language on specialty staffing (44-68%), and subspecialty staffing (39-50%) are moderately consistent. CONCLUSION State policies vary in consistency, a potentially significant barrier to monitoring, regulation, uniform care provision and measurement, and reporting of national-level measures on risk-appropriate care.
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Profit J, Gould JB, Bennett M, Goldstein BA, Draper D, Phibbs CS, Lee HC. Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics 2017; 140:e20170918. [PMID: 28847984 PMCID: PMC5574732 DOI: 10.1542/peds.2017-0918] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California;
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Jeffrey B Gould
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Mihoko Bennett
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, and Center for Predictive Medicine, Duke Clinical Research Institute, School of Medicine, Duke University, Durham, North Carolina
| | - David Draper
- Department of Applied Mathematics and Statistics, Baskin School of Engineering, University of California, Santa Cruz, Santa Cruz, California; and
| | - Ciaran S Phibbs
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- Health Economics Resource Center and the Center for Innovation to Implementation Veteran's Affairs, Palo Alto Health Care System, Palo Alto, California
| | - Henry C Lee
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, School of Medicine, Stanford University and Lucile Packard Children's Hospital, Palo Alto, California
- California Perinatal Quality Care Collaborative, Palo Alto, California
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28
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Abstract
There are numerous measures of perinatal quality endorsed by national agencies such as the National Quality Forum (NQF). The sheer number of metrics may lead to confusion about what these measures truly assess, and how to interpret variation in these measures across hospitals, health care systems, and geographic regions. This review presents a conceptual model for the numerous validated measures, an overview of the types of measures endorsed for perinatal quality by NQF in 2016, and potential measures absent from endorsement by these national bodies.
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Affiliation(s)
- Scott A Lorch
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; PolicyLab, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Center for Perinatal and Pediatric Health Disparities Research, The Children's Hospital of Philadelphia, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Department of Pediatrics, The University of Pennsylvania School of Medicine, 2716 South Street, Room 10-251, Philadelphia, PA 19146, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104, USA.
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29
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Patel RM, Rysavy MA, Bell EF, Tyson JE. Survival of Infants Born at Periviable Gestational Ages. Clin Perinatol 2017; 44:287-303. [PMID: 28477661 PMCID: PMC5424630 DOI: 10.1016/j.clp.2017.01.009] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Periviable births are those occurring from 20 0/7 through 25 6/7 weeks of gestation. Among and within developed nations, significant variation exists in the approach to obstetric and neonatal care for periviable birth. Understanding gestational age-specific survival, including factors that may influence survival estimates and how these estimates have changed over time, may guide approaches to the care of periviable births and inform conversations with families and caregivers. This review provides a historical perspective on survival following periviable birth, summarizes recent and new data on gestational age-specific survival rates, and addresses factors that have a significant impact on survival.
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Affiliation(s)
- Ravi Mangal Patel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, 2015 Uppergate Drive Northeast, 3rd Floor, Atlanta, GA 30322, USA.
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792. Tel 608-262-7926.
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242. Tel 319-356-4006.
| | - Jon E. Tyson
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston and McGovern Medical School, Houston, TX.
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Network analysis: a novel method for mapping neonatal acute transport patterns in California. J Perinatol 2017; 37:702-708. [PMID: 28333155 PMCID: PMC5446293 DOI: 10.1038/jp.2017.20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/20/2017] [Accepted: 02/01/2017] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network. STUDY DESIGN This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression. RESULTS Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001). CONCLUSION Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.
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Kaempf JW, Schmidt NM, Rogers S, Novack C, Friant M, Wang L, Tipping N. The quest for sustained multiple morbidity reduction in very low-birth-weight infants: the Antifragility project. J Perinatol 2017; 37:740-746. [PMID: 28206996 PMCID: PMC5451666 DOI: 10.1038/jp.2017.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 12/23/2016] [Accepted: 01/13/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Can a comprehensive, explicitly directive evidence-based guideline for all therapies that might affect the major morbidities of very low-birth-weight (VLBW) infants help a neonatal intensive care unit (NICU) further improve generally favorable morbidity rates? Can Antifragility principles of provider adaptive growth from stressors, enhanced infant risk assessment and adherence to effective therapies minimize unproven treatments and reduce all morbidities? STUDY DESIGN Prospectively planned observational trial in VLBW infants: control group born October 2011 to September 2013 and study group October 2013 to September 2015. Multi-disciplinary evidence-based review assigned all NICU treatments into one of four distinct categories: (1) always employ this therapy for VLBW infants, (2) never use this therapy, (3) employ this questionable therapy thoughtfully, only in certain circumstances and (4) this therapy has insufficient evidence of efficacy and safety. Extensive staff education emphasized evidence-based potentially better practice (PBP) selection with compliance checks, appreciation of intertwined co-morbidities and prioritizing infant risk reduction strategies. RESULTS Control included 221 infants, mean (s.d.) age 29 (2.6) weeks, birth weight 1129 (257) g and Study included 197 infants, 29 (2.7) weeks, 1093 (292) g. One hundred and four distinct therapies were placed into categories 1 to 4, with 32 specific compliance checks. Overall mean compliance with the process checks during the second era was 70%, high: 100% (exclusive breast milk use), low: 24% (correct pulse oximetry alarm settings). Morbidity and mortality rates did not significantly change during the second era. CONCLUSIONS In our NICU with favorable morbidity rates, an expanded effort using a comprehensive therapy guideline for VLBW infants did not further improve outcomes. We need deeper understanding of continuous quality improvement (CQI) fundamentals, therapy compliance, co-morbidity relationships and enhanced sensitivity of risk assessment. Our innovative Antifragility PBP guideline could be useful to other NICUs seeking improvement in VLBW infant morbidities, as we offer a reasoned and concise template of a broad array of therapies categorized efficiently for transparency and review, designed to enhance responsible CQI decision-making.
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Affiliation(s)
- J W Kaempf
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - N M Schmidt
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - S Rogers
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - C Novack
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - M Friant
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - L Wang
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
| | - N Tipping
- Women and Children's Program, Department of Neonatology, Providence St. Vincent Medical Center, Portland, OR, USA
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32
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Fanelli S, Zangrandi A. Assessment for improving the performance of NICUs: The Italian experience. Health Serv Manage Res 2017; 30:168-178. [PMID: 28548000 DOI: 10.1177/0951484817710856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper describes neonatal intensive care units (NICU) in Italy using a set of organizational variables identifying management profile. The correlations between variables, and how these are impacted by structural aspects of the department or hospital, are investigated. The research was conducted within the 5-year far-reaching and complex SONAR study run by the Italian Neonatal Network, which maps NICU, monitors outcomes of member centres, defines organizational models, and identifies best practices to improve care quality. Seven variables relating to activities, organization processes, and behaviour models used in the SONAR study were used here to assess NICU. Data from 54 Italian NICUs, 1601 nursing staff, and 643 doctors were used. We identified high levels of variation in NICUs for all aspects of organization. We also identified important opportunities for improvement, especially in the areas of performance measurement, quality improvement, and learning for healthcare staff. In terms of structural characteristics, we identified big differences between NICUs in the north and south of Italy. The findings provide a description of NICUs in Italy and identify a set of variables useful for management in assessing NICU, which are among the most complex and costly operational units in a hospital.
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Affiliation(s)
- Simone Fanelli
- Department of Public Management, Universita degli Studi di Parma, Parma, Italy
| | - Antonello Zangrandi
- Department of Public Management, Universita degli Studi di Parma, Parma, Italy
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33
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Tawfik DS, Phibbs CS, Sexton JB, Kan P, Sharek PJ, Nisbet CC, Rigdon J, Trockel M, Profit J. Factors Associated With Provider Burnout in the NICU. Pediatrics 2017; 139:peds.2016-4134. [PMID: 28557756 PMCID: PMC5404731 DOI: 10.1542/peds.2016-4134] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs. METHODS Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression. RESULTS Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence. CONCLUSIONS Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.
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Affiliation(s)
- Daniel S. Tawfik
- Division of Pediatric Critical Care Medicine,,Department of Health Research and Policy
| | - Ciaran S. Phibbs
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, and,Health Economics Research Center and Center for Innovation to Implementation, Veteran’s Affairs Palo Alto Health Care System, Palo Alto, California
| | - J. Bryan Sexton
- Department of Psychiatry, Duke University School of Medicine, and,Duke Patient Safety Center, Duke University Health System, Durham, North Carolina
| | - Peiyi Kan
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, and,California Perinatal Quality Care Collaborative, Palo Alto, California; and
| | - Paul J. Sharek
- Division of Pediatric Hospitalist Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California;,Center for Quality and Clinical Effectiveness, Lucile Packard Children’s Hospital, Palo Alto, California
| | - Courtney C. Nisbet
- Division of Pediatric Hospitalist Medicine, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California;,California Perinatal Quality Care Collaborative, Palo Alto, California; and
| | | | - Mickey Trockel
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, and,California Perinatal Quality Care Collaborative, Palo Alto, California; and
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