Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

aEEG in the first 3 days after extremely preterm delivery relates to neurodevelopmental outcomes

OBJECTIVES

Investigate relationships between aEEG in the first 72 h in extremely preterm infants with 1) infant, medical, and environmental factors, and 2) infant feeding and neurobehavioral outcomes at term and school-age.

METHODS

Sixty-four preterm infants (≤28 weeks gestation) were enrolled within the first 24-hours of life and had two-channel aEEG until 72 h of life. Standardized neurobehavioral and feeding assessments were conducted at term, and parent-reported outcomes were documented at 5-7 years.

RESULTS

Lower aEEG Burdjalov scores (adjusted for gestational age) were related to vaginal delivery (p = 0.04), cerebral injury (p = 0.01), Black race (p < 0.01) and having unmarried parents (p = 0.02). Lower Burdjalov scores related to less NICU Network Neurobehavioral Scale arousal (p = 0.002) at term and poorer BRIEF global executive function (p = 0.004), inhibition (p = 0.007), working memory (p = 0.02), material organization (p = 0.0008), metacognition (p = 0.01), and behavioral regulation (p = 0.02) at 5-7 years. We did not observe relationships of early aEEG to feeding outcomes or sensory processing measures.

CONCLUSION

Early aEEG within the first 72 h of life was related to medical and sociodemographic factors as well as cognitive outcome at 5-7 years.

Interstate Practice Variation and Factors Associated with Antibiotic Use for Suspected Neonatal Sepsis in the United States

OBJECTIVE

This study aimed to estimate national time trends of overall and statewise antibiotic utilization (AU) rates for suspected neonatal sepsis (SNS) in the United States.

STUDY DESIGN

In this cross-sectional study, we used retrospective linked birth cohort and vital records data from the Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research database for the years 2016 to 2020 and analyzed data containing antibiotic use for SNS. The primary outcome was proportional national and state-specific AU rates per 1,000 live births during the birth hospitalization. Secondary outcomes included overall trends and association between maternal education, race, sex, chorioamnionitis, mode of delivery, gestational age at birth, Apgar's scores, and insurance status with antibiotics exposure for SNS among newborns. Contingency tables, two-tailed t-test, and chi-square for independence tests were performed with statistical significance set at p < 0.05.

RESULTS

For a birth cohort of >18 million, 2.2% of infants received antibiotics during birth hospitalization nationwide. There were wide variations in AU among U.S. states and territories, whereas overall treatment rates decreased by 16.1% (95% confidence interval [CI]: 15.2-17.0; p < 0.001). Compared with White newborns, Black newborns had higher AU rates (odds ratio [OR]: 1.33; 95% CI: 1.32-1.34), and Asians had the lowest rates (OR: 0.96; 95% CI: 0.95-0.97). There was a significant difference in mean AU rates by race (p < 0.001). Chorioamnionitis at birth significantly increased the odds for AU (OR: 14.5 ;95% CI: 14.4-14.6), although AU rates for chorioamnionitis showed a significant downward trend (OR: 0.52; 95% CI: 0.50-0.53) during the study period.

CONCLUSION

Our findings suggest that there has been a gradual decline in AU for SNS in more than a third of states in last 5 years. While risk-based management approaches achieve widespread implementation, state- and nationwide quality improvement collaborates might have contributed to the relative decline in antibiotic use in newborns. Further studies are warranted to understand factors related to practice variation in the management of SNS in the United States KEY POINTS: · Early and prolonged use of antibiotics can lead to altered gut microbiome and adverse long-term neonatal outcomes.. · There is considerable clinical practice variation in antibiotic-prescribing practices for suspected neonatal sepsis.. · This cross-sectional study reports the differences in neonatal antibiotic usage patterns by region and maternal factors.. · Antibiotic use should be limited to newborns at high risk of infection and proven sepsis.. · Judicious use of antibiotics can be promoted by following evidence-based approaches to sepsis risk assessment..

Transforming neonatal care with artificial intelligence: challenges, ethical consideration, and opportunities

Artificial intelligence (AI) offers tremendous potential to transform neonatology through improved diagnostics, personalized treatments, and earlier prevention of complications. However, there are many challenges to address before AI is ready for clinical practice. This review defines key AI concepts and discusses ethical considerations and implicit biases associated with AI. Next we will review literature examples of AI already being explored in neonatology research and we will suggest future potentials for AI work. Examples discussed in this article include predicting outcomes such as sepsis, optimizing oxygen therapy, and image analysis to detect brain injury and retinopathy of prematurity. Realizing AI's potential necessitates collaboration between diverse stakeholders across the entire process of incorporating AI tools in the NICU to address testability, usability, bias, and transparency. With multi-center and multi-disciplinary collaboration, AI holds tremendous potential to transform the future of neonatology.

A Call for Early Detection of Cerebral Palsy

Cerebral palsy (CP) is the most common physical disability across the lifespan, but historically, CP has not been diagnosed before the age of 2 years. Barriers to early diagnosis ranged from lack of available biomarkers, absence of curative treatments, perceived stigma associated with a lifelong diagnosis, and a desire to rule out other diagnoses first. Most importantly, the fundamental question that remained was whether children would benefit from earlier detection and intervention given the paucity of research. However, evidence-based guidelines published in 2017 demonstrated that the General Movements Assessment, the Hammersmith Infant Neurological Examination, and neuroimaging can be combined with other elements such as a clinical history and standardized motor assessments to provide the highest predictive value for diagnosing CP as early as age 3 months in high-risk newborns. Implementation of these guidelines has been successful in decreasing the age at CP diagnosis, particularly in high-risk infant follow-up clinics with expertise in performing these assessments. Early detection of CP allows for clinical and research opportunities investigating earlier interventions during a critical period of neuroplasticity, with the goal of improving developmental trajectories for children and their families. New guidelines and research are now being developed with a focus on early, targeted interventions that continue to be studied, along with global detection initiatives.

Evaluating Epidemiologic Trends and Variations in NICU Admissions in California, 2008 to 2018

OBJECTIVE

Previous research suggests increasing numbers of and variation in NICU admissions. We explored whether these trends were reflected in California by examining NICU admissions and birth data in aggregate and among patient and hospital subpopulations more susceptible to variations in care.

METHODS

In this retrospective cohort study, we evaluated NICU utilization between 2008 and 2018 for all live births at hospitals that provide data to the California Perinatal Quality Care Collaborative. We compared hospital- and admission-level data across birth weight (BW), gestational age (GA), and illness acuity categories. Trends were analyzed by using linear regression models.

RESULTS

We identified 472 402 inborn NICU admissions and 3 960 441 live births across 144 hospitals. Yearly trends in NICU admissions remained stable among all births and higher acuity births (mean admission rates 11.9% and 4.1%, respectively). However, analysis of the higher acuity births revealed significant increases in NICU admission rates for neonates with higher BW and GA (BW ≥ 2500g: 1.8% in 2008, 2.1% in 2018; GA ≥ 37 weeks: 1.5% in 2010, 1.8% in 2018). Kaiser hospitals had a decreasing trend of NICU admissions compared to non-Kaiser hospitals (Kaiser: 13.9% in 2008, 10.1% in 2018; non-Kaiser: 11.3% in 2008, 12.3% in 2018).

CONCLUSIONS

Overall NICU admission rates in California were stable from 2008-2018. However, trends similar to national patterns emerged when stratified by infant GA, BW, and illness acuity as well as Kaiser or non-Kaiser hospitals, with increasing admission rates for infants born at higher BW and GA and within non-Kaiser hospitals.

A Saudi Hospital's Experience in the Management of Well-Appearing Neonates at Increased Risk for Early-Onset Bacterial Sepsis

BACKGROUND

Early-onset neonatal bacterial sepsis (EOS) is a serious medical condition where pathogenic bacterial species are isolated from the blood of newborns within the first 72 hours of life. Neonatal healthcare providers face challenges in managing well-appearing newborns born at 35 weeks gestational age or more who are at an increased risk of developing EOS. The American Academy of Pediatrics (AAP) has recommended three approaches for managing EOS. One of these approaches includes enhanced observation to observe the progression of the newborn's clinical condition within the first 48 hours after birth. The AAP recommends that birth centers should adopt institutional approaches that are tailored to their specific local resources and structures. It recommends that the chosen approach is evaluated to identify infrequent negative outcomes and to confirm its effectiveness.

AIMS

To report our experience in managing EOS in newborns born at 35 weeks gestation or later with an increased risk for EOS.

METHODS

This was a review of electronic medical records from the past five years. We included a sample of newborns born at or after 35 weeks gestational age who were at increased risk of EOS and appeared to be healthy. We implemented universal antenatal culture-based screening for Group B streptococcus (GBS). We followed the recommendations of the AAP in 2012 to manage these newborns. We performed a complete blood count (CBC) with differential and C-reactive protein (CRP) tests to predict EOS. We also considered the newborns symptomatic if they displayed any clinical signs of EOS.

RESULTS

A total of 806 newborns were included in the study, out of which 27 (3.3%) of them had symptoms of EOS, while the remaining 782 newborns appeared healthy. Predictive blood tests were performed on 281 (34.9%) of the newborns, out of which 126 (44.8%) of them had a positive test result. However, blood cultures were obtained from 134 (16.6%) of the total cohort. Intravenous antibiotics were administered to 33 (4.1%) of the newborns. All symptomatic newborns had a positive predictive blood test result, and two of them had culture-proven EOS. Blood cultures obtained from the remaining 107 asymptomatic newborns were negative. In this context, 140 newborns needed to be pricked for positive predictive blood tests to predict one case of EOS. However, if the positive predictive blood tests were only performed on symptomatic newborns, then only 14 newborns would need to be pricked to predict one case of EOS.

CONCLUSION

Based on the present study, it is advised to follow the current AAP recommendation against predicting EOS by solely relying on CBC with differential or CRP. The study suggests that the enhanced observation approach is a more sensible option for managing EOS, but this needs to be confirmed in a larger study.

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm.

STUDY DESIGN

Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS. The primary outcome was a composite rate of death, 911 call-triggered transports, or readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening event, or brief resolved unexplained events within 30 days of discharge. Outcomes of infants born in the periods of CSTS and after discontinuation were compared.

RESULTS

Twelve of 14 hospitals initially utilized CSTS and contributed patients to the CSTS period; 71.4% of neonatal intensive care unit (NICU) patients and 26.9% of non-NICU infants were screened. All hospitals participated in the discontinuation period; 0.1% was screened. Rates of the unadjusted primary outcome were 1.02% in infants in the CSTS period (n = 21 122) and 1.06% after discontinuation (n = 20 142) (P = .76). The aOR (95% CI) was 0.95 (0.75, 1.19). Statistically insignificant differences between periods were observed in components of the primary outcome, gestational age strata, NICU admission status groups, and other secondary analyses.

CONCLUSIONS

Discontinuation of CSTS in a large integrated health care network was not associated with a change in 30-day postdischarge adverse outcomes. CSTS's value as a standard predischarge assessment deserves further evaluation.

The association of regional perinatal risk factors and neonatal intensive care capacity for Military Health System-insured newborns

OBJECTIVE

To characterize hospitals where military-insured newborns received care and test the association of regional perinatal risk with neonatal intensive care unit (NICU) capacity.

STUDY DESIGN

We identified birth hospitals for live newborns October 2015-December 2018 (n = 296,568) and assigned newborns to health service areas (HSAs). Perinatal risk factors and the number of neonatal special care beds and neonatologists were calculated at HSA levels. Cross-sectional correlation analyses assessed perinatal risk factors and capacity across HSAs.

RESULTS

27.0% (n = 10) of military birth hospitals had special care beds (intermediate and intensive) compared with 44.3% of civilian hospitals (n = 1224; p < 0.05). The number of special care beds and neonatologists per newborn varied more than twofold across regions and were only weakly associated with the proportion of higher risk newborns (R2 < 0.05).

CONCLUSIONS

The lack of meaningful association of regional perinatal risk with NICU capacity poses challenges for effective specialized care among military-associated newborns.

Using Quality Improvement to Improve Value and Reduce Waste

Value is defined as health outcomes achieved per dollar spent. Addressing value in quality improvement (QI) efforts can help optimize patient outcomes while reducing unnecessary spending. In this article, we discuss how QI focused on reducing morbidities frequently reduces costs, and how proper cost accounting can help demonstrate improvements in value. We provide examples of high-yield opportunities for value improvement in neonatology and review the literature associated with these topics. Opportunities include reducing neonatal intensive care admissions for low-acuity infants, sepsis evaluations in low-risk infants, unnecessary total parental nutrition use, and utilization of laboratory and imaging.

Clinical use of gastric antisecretory drugs in pediatric patients with gastroesophageal reflux disease: a narrative review

BACKGROUND AND OBJECTIVE

Gastroesophageal reflux (GER) is a common condition in infants. Usually, it resolves spontaneously in 95% of cases within 12-14 months of age, but gastroesophageal reflux disease (GERD) may develop in some children. Most authors do not recommend pharmacological treatment of GER, while the management of GERD is debated. The aim of this narrative review is to analyze and summarize the available literature on the clinical use of gastric antisecretory drugs in pediatric patients with GERD.

METHODS

References were identified through MEDLINE, PubMed, and EMBASE search engines. Only articles in English were considered. The following keywords were used: "gastric antisecretory drugs", "H2RA", "PPI", "ranitidine", "GERD", "infant", "child".

KEY CONTENT AND FINDINGS

Increasing evidence of poor efficacy and potential risks of proton pump inhibitors (PPIs) is emerging in neonates and infants. Histamine-2 receptor antagonists (H2RAs), including ranitidine, have been used successfully in older children, although less effective than PPIs at relieving symptoms and healing GERD. However, in April 2020, both the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) requested manufacturers of ranitidine to remove all ranitidine products from the market due to the risk of carcinogenicity. Pediatric studies comparing effectiveness and safety of different acid-suppressing treatments for GERD are generally inconclusive.

CONCLUSIONS

A proper differential diagnosis between GER and GERD is crucial to avoid the overuse of acid-suppressing medications in children. Further research should be directed towards the development of novel antisecretory drugs, with proven efficacy and good safety profile, for treating pediatric GERD, particularly in newborns and infants.

Using the Neonatal Intensive Care Unit Wisely: A National Survey of Clinicians Regarding Practices for Lower-Acuity Care

OBJECTIVE

The objective of this study was to document the practices and preferences of neonatal care stakeholders regarding location and duration of care for newborns with low illness acuity.

STUDY DESIGN

We developed a survey instrument that comprised 14 questions across 2 global scenarios and 7 specific clinical conditions. The latter included apnea of prematurity, gestational age for neonatal intensive care unit admission, jaundice, neonatal opioid withdrawal, thermoregulation, and sepsis evaluation. Respondents reported their current practice and preferences for an alternative approach. We administered the survey to individuals in the membership email distribution lists of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine, the National Association of Neonatal Nurses, and the Vermont Oxford Network.

RESULTS

Of 2284 respondents, 53% believed that infants were, in general, admitted to a higher level of care than was required, and only 13% reported that the level of care was too low. Length of stay was perceived to be generally too long by 46% of respondents and too short by 21%. Across 10 specific clinical questions, there was substantial variability in current practice and up to 35% of respondents reported discordance between current and preferred practice. These respondents preferred a lower level of care in 8 of 10 scenarios.

CONCLUSIONS

A multidisciplinary sample of US clinicians reported significant variation in the level and duration of care for infants with low illness acuity. Among individuals reporting discordance between current and preferred practice, a majority believed that current management could be accomplished in a lower level of care location.

Discharge Practices for Infants with Bronchopulmonary Dysplasia: A Survey of National Experts

OBJECTIVE

To establish consensus practices among a panel of national experts for the discharge of premature infants with bronchopulmonary dysplasia (BPD) from the hospital to home.

STUDY DESIGN

We conducted a Delphi study that included US neonatologists and pediatric pulmonologists from the Bronchopulmonary Dysplasia Collaborative to establish consensus practices-defined as recommendations with at least 80% agreement-for infants with BPD being discharged from the hospital. Specifically, we evaluated recommendations for diagnostic tests to be completed around discharge, follow-up respiratory care, and family education.

RESULTS

Thirty-one expert participants completed 3 rounds of surveys, with a 99% response rate (92 of 93). Consensus was established that infants with moderate-severe BPD (ie, those who remain on respiratory support at 36 weeks) and those discharged on oxygen should be targeted for in-person pulmonary follow-up within 1 month of hospital discharge. Specialized neonatal follow-up is an alternative for infants with mild BPD. Infants with moderate or severe BPD should have an echocardiogram performed after 36 weeks to screen for pulmonary hypertension. Infants with BPD warrant additional evaluations if they have growth restriction or poor growth, pulmonary hypertension, or tachypnea and if they are discharged to home on oxygen, diuretics, or nonoral feeds.

CONCLUSIONS

This Delphi survey establishes expert consensus around best practices for follow-up respiratory management and routine evaluation for infants with BPD surrounding neonatal discharge. Areas of disagreement for which consensus was not established are discussed.

Successful establishment and five-year sustainability of a neonatal-specific antimicrobial stewardship program in a low middle-income country

Introduction: Antibiotic use varies substantially among neonatal intensive care units (NICUs) without any appreciable impact on outcomes. An increased use of antimicrobials has been reported in low-middle income countries. This raises the concern for potential overuse of antibiotics in a fragile patient population, thus increasing the rates of multidrug resistant organisms and affecting the developing microbiome. The presence of a neonatal-specific antimicrobial stewardship program can aid with the judicious use of antibiotics in the neonatal population and thus decrease the overuse of such medications. Methods: In this quality improvement project, we established and implemented a neonatal-specific antimicrobial stewardship program with the aim of reducing antimicrobial use in the neonatal intensive care units within a year of starting. Several interventions using a multidisciplinary approach included implementing standard algorithms, direct audit and feedback, and automated hard stops. Results: These series of interventions led to a 35% decrease in antimicrobial usage in the first 3 months and further decrease was seen with a median of 63% decline for a total of 5 years after project implementation. The use of the most commonly prescribed antibiotics, ampicillin and gentamicin, decreased by 63% and 79%, respectively. There was no evidence that this change in practice affected or jeopardized patient outcomes. Additionally, it showed sustainability and resilience despite the many challenges such as COVID-19 pandemic, political and financial unrest, and healthcare sector collapse. Discussion: This model-based and multidisciplinary low-cost approach can lead to marked improvement affecting neonatal outcomes and can be replicated in other similar centers.

Evaluation of antibiotic stewardship among near-term and term infants admitted to a neonatal unit

To evaluate the safety and effectiveness of evidence-based antibiotic stewardship in a neonatal unit in China. The study period consisted of two phases, one retrospective (the baseline period, January to December 2018, and the transition period, January 2019 to August 2020) and one prospective intervention period (September 2020 to August 2021). During the prospective period, evidence-based antibiotic stewardship was applied to neonates with suspected infections, pneumonia, and culture-negative sepsis. The antibiotic stewardship included the observation form of neonatal infections, antibiotic therapy of no more than 48 h for suspected infections, and 5 days for pneumonia and culture-negative sepsis. The change in antibiotic use measured by days of therapy per 1000 patient-days between the baseline and intervention period was analyzed. Safety outcomes included reinitiation of antibiotics within 14 days, length of stay, occurrence of late-onset sepsis and necrotizing enterocolitis (Bell stage ≥ II), multidrug-resistant organism infections, and mortality. A total of 7705 neonates were enrolled during the baseline (n = 4804) and the intervention periods (n = 2901). The total antibiotic usage during the baseline period was 771 days of therapy per 1000 patient-days, while that was 525 days of therapy per 1000 patient-days during the intervention period, indicating a 32% decrease in antibiotic consumption. No significant difference in safety outcomes was observed between the baseline and intervention period (P > 0.05), whereas the length of stay was longer during the intervention period (P < 0.001).

CONCLUSION

The evidence-based antibiotic stewardship can safely and effectively reduce antibiotic use and shorten the duration of therapy in the neonatal unit.

WHAT IS KNOWN

• Overuse of antibiotics has been associated with adverse events in neonates, including necrotizing enterocolitis, multidrug-resistant organism infections, and death. • More clinical effectiveness evidence is needed to support antibiotic stewardship of neonates in China.

WHAT IS NEW

• Using prospective audit, targeted stewardship interventions, this study shows that a 32% reduction in overall antibiotic consumption was achieved safely. • Implementation of evidence-based neonatal antibiotic stewardship, including the observation form of neonatal infections, antibiotic therapy of no more than 48 h for suspected infections, and 5 days for pneumonia and culture-negative sepsis, is safe and effective among newborns in a developing country.

[Antibiotic use in very low birth weight/extremely low birth weight infants in 15 hospitals in Jiangsu Province of China: a multicenter survey]

OBJECTIVES

To investigate the current status of antibiotic use in very low birth weight/extremely low birth weight infants in Jiangsu Province of China, and to provide a clinical basis for the quality and improvement of antibiotic management in the neonatal intensive care unit (NICU).

METHODS

A retrospective analysis was performed on the data on general conditions and antibiotic use in the very low birth weight/extremely low birth weight infants who were admitted to 15 hospitals of Jiangsu Province from January 1, 2019 to December 31, 2020. A questionnaire containing 10 measures to reduce antibiotic use was designed to investigate the implementation of these intervention measures.

RESULTS

A total of 1 920 very low birth weight/extremely low birth weight infants were enrolled, among whom 1 846 (96.15%) were treated with antibiotic, and the median antibiotic use rate (AUR) was 50/100 patient-days. The AUR ranged from 24/100 to 100/100 patient-days in the 15 hospitals. After adjustment for the confounding factors including gestational age, birth weight, and neonatal critical score, the Poisson regression analysis showed that there was a significant difference in the adjusted AUR (aAUR) among the hospitals (P<0.01). The investigation results showed that among the 10 measures to reduce antibiotic use, 8 measures were implemented in less than 50% of these hospitals, and the number of intervention measures implemented was negatively correlated with aAUR (rs=-0.564, P=0.029).

CONCLUSIONS

There is a high AUR among the very low birth weight/extremely low birth weight infants in the 15 hospitals of Jiangsu Province, with a significant difference among hospitals. The hospitals implementing a relatively few measures to reduce antibiotic use tend to have a high AUR. It is expected to reduce AUR in very low birth weight/extremely low birth weight infants by promoting the quality improvement of antibiotic use management in the NICU.

Choosing Wisely in Adult Hospital Medicine: Co-creation of New Recommendations for Improved Healthcare Value by Clinicians and Patient Advocates

BACKGROUND

The American Board of Internal Medicine Foundation's Choosing Wisely campaign has resulted in a vast number of recommendations to reduce low-value care. Implementation of these recommendations, in conjunction with patient input, remains challenging.

OBJECTIVE

To create updated Society of Hospital Medicine Adult Hospitalist Choosing Wisely recommendations that incorporate patient input from inception.

DESIGN AND PARTICIPANTS

This was a multi-phase study conducted by the Society of Hospital Medicine's High Value Care Committee from July 2017 to January 2020 involving clinicians and patient advocates.

APPROACH

Phase 1 involved gathering low-value care recommendations from patients and clinicians across the USA. Recommendations were reviewed by the committee in phase 2. Phase 3 involved a modified Delphi scoring in which 7 committee members and 7 patient advocates voted on recommendations based on strength of evidence, potential for patient harm, and relevance to either hospital medicine or patients. A patient-friendly script was developed to allow advocates to better understand the clinical recommendations.

KEY RESULTS

A total of 1265 recommendations were submitted by clinicians and patients. After accounting for similar suggestions, 283 recommendations were categorized. Recommendations with more than 10 mentions were advanced to phase 3, leaving 22 recommendations for the committee and patient advocates to vote upon. Utilizing a 1-5 Likert scale, the top combined recommendations were reducing use of opioids (4.57), improving sleep (4.52), minimizing overuse of oxygen (4.52), reducing CK-MB use (4.50), appropriate venous thromboembolism prophylaxis (4.43), and decreasing daily chest x-rays (4.43).

CONCLUSIONS

Specific voting categories, along with the use of patient-friendly language, allowed for the successful co-creation of recommendations.

A quality improvement initiative to reduce acid-suppressing medication exposure in the NICU

BACKGROUND

Acid-suppressing medications (ASMs) are commonly prescribed in the neonatal intensive care unit (NICU), in particular among preterm infants, despite well-established adverse effects and little evidence to support efficacy.

LOCAL PROBLEM

We sought to develop an initiative to reduce ASM exposure in our predominantly inborn level III NICU. Our specific aim was to reduce the number of nonindicated ASM prescriptions by 50% within a 12-month period.

METHODS

Our multidisciplinary team developed an evidence-based guideline defining indications for ASM prescription in a level III NICU. Plan-do-study-act cycles included staff education, formal clinical practice guideline implementation, and implementation of standardized documentation tools in the electronic health record (EHR). Outcome measures were the number of nonindicated and total inpatient prescriptions started per month, duration of ASM prescription, and number of prescriptions continued after NICU discharge. Balancing measures were the number of patients started on thickened feeds and number of patients discharged home on nasogastric tube feeds. We used statistical process control and Pareto charts to assess these measures over a 12-month baseline period, 9-month implementation period, and 19-month post-implementation period spanning September 2017-December 2020.

RESULTS

Nonindicated ASM prescriptions decreased from median 3 to 0 per month from the baseline to post-implementation period. Simultaneously, the median number of ASM prescriptions at discharge declined from 2 to 0 per month. The median duration of inpatient prescriptions declined from 23 to 7 days. Rates of patients started on thickened feeds and patients discharged home on nasogastric tube feeds remained stable throughout the study.

CONCLUSION

Enactment of an evidence-based guideline was associated with a substantial decline in nonindicated ASM use in our NICU and a decline in duration of exposure to ASM's when prescribed. Our interventions proved effective in altering clinical practice and could be applied to other NICUs with similar patient populations aiming to reduce ASM use.

Amplitude-integrated EEG recorded at 32 weeks postconceptional age. Correlation with MRI at term

OBJECTIVE

The study aims to establish the role of late aEEG (scored by Burdjalov) in predicting brain maturation as well as abnormalities evaluated at term equivalent age (TEA) by brain MRI.

METHODS

91 infants born before 30 wks gestation underwent an aEEG monitoring at 32 wks postconceptional age (PCA). aEEG, was correlated with TEA MRI, scored by Kidokoro.

RESULTS

A significant correlation between the aEEG score and the MRI scores was found. The same results were obtained for the aEEG continuity score; cyclicity and bandwidth scores were associated with grey matter and cerebellar MRI items. Moreover, a correlation between aEEG and cEEG recorded both at 32 and 40 wks PCA, was found.

CONCLUSIONS

aEEG monitoring can be predictive of MRI findings at TEA, suggesting that it could be implemented as a useful tool to support ultrasound to help identify neonates who will benefit from early intervention services.

Charge Nurses Taking Charge, Challenging the Culture of Culture-Negative Sepsis, and Preventing Central-Line Infections to Reduce NICU Antibiotic Usage

OBJECTIVE

We aimed to reduce our monthly antibiotic usage rate (AUR, days of treatment per 1,000 patient-days) in the neonatal intensive care unit (NICU) from a baseline of 330 (July 2015-April 2016) to 200 by December 2018.

STUDY DESIGN

We identified three key drivers as follows: (1) engaging NICU charge nurses, (2) challenging the culture of culture-negative sepsis, and (3) reducing central-line associated bloodstream infections (CLABSI). Our main outcome was AUR. The percentage of culture-negative sepsis that was treated with antibiotics for >48 hours and CLABSI was our process measure. We used hospital cost/duration of hospitalization and mortality as our balancing measures.

RESULTS

After testing several plan-do-study-act (PDSA) cycles, we saw a modest reduction in AUR from 330 in the year 2016 to 297 in the year 2017. However, we did not find a special-cause variation in AUR via statistical process control (SPC) analysis (u'-chart). Thereafter, we focused our efforts to reduce CLABSI in January 2018. As a result, our mean AUR fell to 217 by December 2018. Our continued efforts resulted in a sustained reduction in AUR beyond the goal period. Importantly, cost of hospitalization and mortality did not increase during the improvement period.

CONCLUSION

Our sequential quality improvement (QI) efforts led to a reduction in AUR. We implemented processes to establish a robust antibiotic stewardship program that included antibiotic time-outs led by NICU charge nurses and a focus on preventing CLABSI that were sustained beyond the QI period.

KEY POINTS

· This is a quality improvement project to reduce antibiotic usage in NICU.. · Charge nurses should take charge to reduce infections in NICU.. · Central line infections should be reduced to decrease antibiotic usage..

Ultrasound imaging of preterm brain injury: fundamentals and updates

Neurosonography has become an essential tool for diagnosis and serial monitoring of preterm brain injury. Preterm infants are at significantly higher risk of hypoxic-ischemic injury, intraventricular hemorrhage, periventricular leukomalacia and post-hemorrhagic hydrocephalus. Neonatologists have become increasingly dependent on neurosonography to initiate medical and surgical interventions because it can be used at the bedside. While brain MRI is regarded as the gold standard for detecting preterm brain injury, neurosonography offers distinct advantages such as its cost-effectiveness, diagnostic utility and convenience. Neurosonographic signatures associated with poor long-term outcomes shape decisions regarding supportive care, medical or behavioral interventions, and family members' expectations. Within the last decade substantial progress has been made in neurosonography techniques, prompting an updated review of the topic. In addition to the up-to-date summary of neurosonography, this review discusses the potential roles of emerging neurosonography techniques that offer new functional insights into the brain, such as superb microvessel imaging, elastography, three-dimensional ventricular volume assessment, and contrast-enhanced US.

2021 Update on Pediatric Overuse

This update on pediatric medical overuse identifies and provides concise summaries of 10 impactful articles related to pediatric medical overuse from the years 2019 to 2020.

Reducing Early Antibiotic Use: A Quality Improvement Initiative in a Level III Neonatal Intensive Care Unit

Antibiotic burden is a critical issue in neonatal intensive care units (NICU) and antibiotic use is considered a quality indicator of neonatal care. Our aim was to optimize antibiotic use through a quality improvement (QI) initiative that included revision of departmental protocols and implementation of a surveillance system based on process indicators.

METHODS

This is descriptive study of a cohort of all very low birth weight (VLBW) infants admitted to the NICU from 2014 to 2019. A series of QI interventions were made during the study period and included departmental protocols and the implementation of a surveillance system based on process indicators. The primary outcome was the percentage of VLBW infants who had received early antibiotics (ampicillin, gentamicin, or cefotaxime on the day of birth or day 1 or 2 after birth), antibiotics for longer than 3 days (despite negative blood culture), or no antibiotics.

RESULTS

During the study period, a significant relative reduction was seen in the proportion of VLBW infants administered early antibiotics (46%; p < 0.01) and in infants provided antibiotics for longer than 3 days (90%; p < 0.01). Additionally, the percentage of VLBW with "no antibiotics" during their NICU stay increased fivefold (6 to 30%; p < 0.001).

CONCLUSIONS

In our NICU, the implementation of a QI initiative that is based on affordable methods to track process indicators and evaluate the results led into a significant reduction in antibiotic exposure in VLBW infants. This approach is easy to implement in other NICUs as well.

Choosing Wisely in Pediatric Hospital Medicine: 5 New Recommendations to Improve Value

OBJECTIVES

The health care system faces ongoing challenges due to low-value care. Building on the first pediatric hospital medicine contribution to the American Board of Internal Medicine Foundation Choosing Wisely Campaign, a working group was convened to identify additional priorities for improving health care value for hospitalized children.

METHODS

A study team composed of nominees from national pediatric medical professional societies was convened, including pediatric hospitalists with expertise in clinical care, hospital leadership, and research. The study team surveyed national pediatric hospitalist LISTSERVs for suggestions, condensed similar responses, and performed a literature search of articles published in the previous 10 years. Using a modified Delphi process, the team completed a series of structured ratings of feasibility and validity and facilitated group discussion. The sum of final mean validity and feasibility scores was used to identify the 5 highest priority recommendations.

RESULTS

Two hundred seven respondents suggested 397 preliminary recommendations, yielding 74 unique recommendations that underwent evidence review and rating. The 5 highest-scoring recommendations had a focus on the following aspects of hospital care: (1) length of intravenous antibiotic therapy before transition to oral antibiotics, (2) length of stay for febrile infants evaluated for serious bacterial infection, (3) phototherapy for neonatal hyperbilirubinemia, (4) antibiotic therapy for community-acquired pneumonia, and (5) initiation of intravenous antibiotics in infants with maternal risk factors for sepsis.

CONCLUSIONS

We propose that pediatric hospitalists can use this list to prioritize quality improvement and scholarly work focused on improving the value and quality of patient care for hospitalized children.

A Quality Improvement Project to Reduce Antibiotic Utilization and Ancillary Laboratory Tests in the Appraisal of Early-Onset Sepsis in the NICU

BACKGROUND

Diagnosis and treatment of early-onset sepsis (EOS) of the newborn remains a controversial issue among providers due to the non-infectious symptomology which exists in the newborn period.

METHODS

Pre/post interventional quality improvement project in a level III NICU to reduce antibiotic utilization and ancillary laboratory tests with the introduction of an evidence-based guideline for the evaluation of EOS in the NICU.

RESULTS

Primary outcome measures include mean number of empiric antibiotic treatment days and utilization rate (AUR), number of laboratory tests ordered, and incidence of unwarranted antibiotic therapy beyond the 48-h rule out period. Mean empiric antibiotic treatment days decreased from 2.94 to 1.58 days and overall antibiotic use decreased from 73.7% to 57.1%. Likewise, the mean AUR decreased from 212.5 to 147.6 days of therapy per 1000 patient days. There was an 86% decline in the number of ancillary tests and unwarranted antibiotic use beyond 48- h was reduced by 74%.

DISCUSSION

Guidelines for EOS of the newborn should include a thorough baseline evaluation of the drivers of antibiotic use to create an evidence-based foundation. Reducing unnecessary antibiotic use and EOS evaluations in a safe and effective manner have the potential to lower consumer and healthcare expenditures while improving the long-term health of the newborn in the NICU.

CONCLUSIONS

These findings emphasize the importance of implementing an evidence-based protocol for antibiotic stewardship in the NICU. With further research there is the potential to improve the healthcare of newborns while reducing expenditures in a safe, effective evaluation of EOS in the newborn population.

Immature control of breathing and apnea of prematurity: the known and unknown

This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.

Survey of Quaternary Neonatal Management of Posthemorrhagic Hydrocephalus

OBJECTIVE

 This study aimed to determine clinical care practices for infants at risk for posthemorrhagic hydrocephalus (PHH) across level IV neonatal intensive care units (NICUs).

STUDY DESIGN

 Cross-sectional survey that addressed center-specific surveillance, neurosurgical intervention, and follow-up practices within the Children's Hospitals Neonatal Consortium.

RESULTS

 We had a 59% (20/34 sites) response rate, with 10 sites having at least two participants. Respondents included neonatologists (53%) and neurosurgeons (35%). Most participants stated having a standard guideline for PHH (79%). Despite this, 42% of respondents perceive inconsistencies in management. Eight same-center pairs of neonatologists and neurosurgeons were used to determine response agreement. Half of these pairs disagreed on nearly all aspects of care. The greatest agreement pertained to a willingness to adopt a consensus-based protocol.

CONCLUSION

 Practice variation in the management of infants at risk of PHH in level IV NICUs exists despite the perception that a common practice is available and used.

KEY POINTS

· Practice variation exists despite the perception that common practices are available/used for PHH.. · Our survey had same-center pairs of neonatologist and neurosurgeons to determine response agreement.. · The greatest agreement pertained to a willingness to adopt a consensus-based protocol..

Medication utilization in children born preterm in the first two years of life

OBJECTIVE

To compare medications dispensed during the first 2 years in children born preterm and full-term.

STUDY DESIGN

Retrospective analysis of claims data from a commercial national managed care plan 2008-2019. 329,855 beneficiaries were enrolled from birth through 2 years, of which 25,408 (7.7%) were preterm (<37 weeks). Filled prescription claims and paid amount over 2 years were identified.

RESULTS

In preterm children, the number of filled prescriptions was 1.4 times and cost was 3.8 times that of full-term children. Number and cost of medications were inversely related to gestational age. Differences peak at 4-9 months and resolve by 19 months after discharge. Palivizumab, ranitidine, albuterol, lansoprazole, budesonide, and prednisolone had the greatest differences in utilization.

CONCLUSION

Prescription medication utilization among preterm children under 2 years is driven by palivizumab, anti-reflux, and respiratory medications, despite little evidence regarding efficacy for many medications and concern for harm with certain classes.

Implementation of a top five list to identify medical overuse in general practice according to patients' viewpoint in 2019 in France

BACKGROUND

There is a current trend to reassess the adequacy of care. Establishing top five lists by involving patients is one way to address medical overuse. The objective of this study was to establish a patients' top five list in general practice in France. The secondary objective was to identify selection criteria.

METHOD

Patients from the web-based cohort GrippeNet.fr were invited to establish their top five list from 15 care procedures previously selected by general practitioners on the basis of medical overuse. The care procedures were presented on a web-interface with guides written with the help of a patient association. A questionnaire was used to explore factors that may have influenced the choices of the participants.

RESULTS

In total, 691 patients established the following top five list: 1/ Prescription of antibiotics for acute bronchitis, nasopharyngitis, otitis media with effusion, or uncomplicated influenza; 2/ Prescription of benzodiazepine and benzodiazepine-like agents for insomnia, generalised anxiety and all indications for older patients; 3/ Prescription of a homeopathic treatment (Influenzinum) for flu prevention; 4/ Prescription of antitussive or expectorant agents for acute cough or acute bronchitis care; 5/ Prescription of statins for the primary prevention of cardio-vascular risk in older patients. More than 70% of participants gave importance to the recommendations, effectiveness, and tolerance of the care procedures, whereas only half considered the cost.

CONCLUSION

This study is the first to establish a patient's top-five list in general practice. This list provides direction for deciding the main targets in limiting medical overuse.

Are we over-treating hypoxic spells in preterm infants?

A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.

Comparative performance of head ultrasound and MRI in detecting preterm brain injury and predicting outcomes: A systematic review

AIM

To systematically review the literature to compare the performance of head ultrasound (HUS) and magnetic resonance imaging (MRI) in their ability to detect brain injury and their predictive value for neurodevelopmental outcomes.

METHODS

This was a systematic review based on literature search in three electronic databases (MEDLINE, EMBASE, Cochrane Library) and additional sources for studies on routine brain injury screening in preterm neonates published during 2000-May 2020. Studies were included if they reported on the comparative performance of HUS and MRI in detecting preterm brain injury and/or their predictive value for neurodevelopmental outcomes. Findings from the included studies underwent narrative synthesis.

RESULTS

Forty-six studies were included. In comparison with HUS, MRI detected more anomalies and provided more details on the severity and the extent of preterm brain injury, particularly for white matter injury and cerebellar haemorrhage. Neonatal neuroimaging predicted outcomes with high negative predictive value but relatively low positive predictive value. The prognostic value of neonatal neuroimaging varied according to several factors including modality and timing of imaging, and tools used for grading brain injury.

CONCLUSION

Compared with HUS, MRI offers a better characterisation of preterm brain injury and may enhance the ability to predict neurodevelopmental outcomes.

Unbiasing costs? An appraisal of economic assessment alongside randomized trials in neonatology

Economic evaluations performed alongside randomized controlled trials benefit from the protections against bias inherent in randomization. In this systematic review, we assessed the frequency and quality of economic assessments alongside randomized controlled trials of interventions in neonates published between 1990 and 2016. Over that period, 58 economic assessments were published, corresponding to approximately 2% of RCTs. We noted significant methodological limitations of these studies, including limitation of included costs to the health sector or payer rather than broader categories such as family or community expenditures (81%), short time horizon for cost measurement (less than one year in 60%), lack of reporting of uncertainty (26%), and infrequent analysis of costs and effects in a single metric (combined in 45%). Strategies for improving the quality and frequency of economic evaluations in neonatology are discussed, including selection of appropriate trials, funding, and peer review.

Economics at the frontline: Tools and tips for busy clinicians

Frontline providers of neonatal care have a moral imperative to enhance value and inform senior administrators of how to most efficiently spend healthcare dollars. This article argues that the frontline is the ideal setting to pursue these efforts, offers recommendations for how to measure value, and describes five simple yet effective concrete tools that can improve value. It concludes with tips on advancing a value-added agenda through the Model for Improvement and advice for teams on ways of approaching senior leaders to help align unit-level aims with system-level goals and mission. Armed with these instruments, multidisciplinary teams can help ensure that neonatal care remains at the forefront of high-value healthcare.

Comparing head ultrasounds and susceptibility-weighted imaging for the detection of low-grade hemorrhages in preterm infants

OBJECTIVE

Intraventricular hemorrhage (IVH) is a complication of prematurity. Grades III and IV IVH lead to significant morbidity, but mounting evidence shows low-grade IVH (grades I-II) may be associated with adverse sequelae. Head ultrasounds (HUS) are used to screen infants for IVH but may miss low-grade IVH. Our study compared the results of HUS around 7 days of age to susceptibility-weighted imaging (SWI) obtained at term-corrected age in infants born at <30 wGA.

STUDY DESIGN

Infants <30 weeks gestational age (GA) with an HUS and MRI at admission to UF Health were identified by a retrospective chart review. Images were re-read by a pediatric neuroradiologist.

RESULTS

Ninety-four infants with a mean GA of 25.8 weeks were identified. Of those with normal HUS, 50% had low-grade IVH on the term-corrected MRI.

CONCLUSIONS

HUS are effective for screening for high-grade IVH. SWI is more sensitive in identifying low-grade IVH.

Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary

Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes.

Reducing Duration of Antibiotic Use for Presumed Neonatal Early-Onset Sepsis in Greek NICUs. A "Low-Hanging Fruit" Approach

Antibiotics are commonly prescribed in Neonatal Intensive Care Units (NICU), where stewardship interventions are challenging. Lowering antibiotic consumption is desperately needed in Greece, a country with high antibiotic resistance rates. We sought to assess the effectiveness of a low-cost and -resource intervention to reduce antibiotic use in Greek NICUs implementing a "low-hanging fruit" approach. A prospective quasi-experimental study was conducted in 15/17 public NICUs in Greece (9/2016-06/2019). The intervention selected was discontinuation of antibiotics within 5 days for neonates with gestational age ≥ 37 weeks, no documented signs or symptoms of sepsis, CRP ≤ 10 mg/L and negative cultures within 3 days of antibiotic initiation. Impact was evaluated by the percentage of discontinued regimens by day 5, length of therapy (LOT) and stay. Trends of antibiotic consumption were assessed with days of therapy (DOT) per 1000 patient-days. Overall, there was a 9% increase (p = 0.003) of antibiotic discontinuation in ≤5 days. In total, 7/13 (53.8%) units showed a ≥10% increase. Overall, 615 days on antibiotics per 1000 patients were saved. Interrupted time-series analysis established a declining trend in DOT/1000 patient-days relative to the pre-intervention trend (p = 0.002); a monthly decrease rate of 28.96 DOT/1000 patient-days (p = 0.001, 95%CI [-45.33, -12.60]). The intervention had no impact on antibiotic choice. Antibiotic use was successfully reduced in Greek NICUs using a "low-hanging fruit" approach. In resource-limited settings, similar targeted stewardship interventions can be applied.

An assessment of prevalence and expenditure associated with discharge brain MRI in preterm infants

To assess national expenditure associated with preterm-infant brain MRI and potential impact of reduction per Choosing Wisely campaign 2015 recommendation to “avoid routine screening term-equivalent or discharge brain MRIs in preterm-infants”. Cross-sectional U.S. trend data from the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) database (2006, 2009, 2012, 2016) was used to estimate overall national expenditure associated with brain MRI among infants with gestational age (GA) ≤36 weeks, and also when classified as ‘not indicated’ (NI-MRI) i.e., equivalent to routine use without clinical indications and regarded as low-value service (LVS). Associated cost was determined by querying CMS-database for physician-fee-schedules to find the highest global procedure-cost per cycle, then adjusting for inflation. Sensitivity-analyses were conducted to account for additional clinical charges associated with NI-MRI. 3,768 (0.26%) of 1,472,236 preterm-infants had brain MRI across all cycles (inflation-adjusted total $3,690,088). Overall proportion of brain MRIs increased across 2006–2012 from 0.25%-0.33% but decreased in 2016 to 0.16% (P<0.001). Inflation-adjusted overall expenditure by cycle was: 2006, $1,299,130 (95% CI: $987,505, $1,610,755); 2009, $1,194,208 (95% CI: $873,487, $1,516,154); 2012, $931,836 (95% CI: $666,114, $1,197,156); and 2016, $264,648 (95% CI: $172,061, $357,280). Prevalence for NI-MRI in 2006, 2009, 2012 and 2016 was 86% (n = 809), 88% (n = 940), 89% (n = 1028) and 50% (n = 299), respectively; and 70% were in infants 35–36 weeks GA. NI-MRI prevalence was not different over time by payer-type (Medicaid, private), sex or race/ethnicity (white, black, Hispanic); larger hospital size was significantly associated across 2006–2012 but this declined for all sizes in 2016, with most decline in larger hospitals (P for interaction <0.05). NI-MRI expenditure sensitivity-analysis with addition of cycle median total-admission-charge to inflation-adjusted CMS-fee was $1,190,919/$518,343, for 2012/2016 cycles respectively. National MRI prevalence in preterm infants (both overall and LVS) and associated expenditure decreased substantially post recommendation; however, annual savings are modest and unlikely to be >$1.2 million.

Quantifying Medication Exposure in Very Low Birth Weight Neonates

OBJECTIVE

Very low birth weight (VLBW) infants are exposed to medications with insufficient evidence describing pharmacokinetics and safety. Objective was to quantify and identify risk factors associated with the highest quartile of medication exposure.

STUDY DESIGN

Retrospective record review of VLBW infants admitted to a level-IV neonatal intensive care unit (NICU). We obtained baseline clinical and demographic characteristics, as well as data on all medications received during admission. Characteristics of patients within the upper quartile of medication use were compared with remaining patients.

RESULTS

Identified 106 infants, mean birth weight (BW) = 961 g, gestational age = 27.3 weeks. Infants received a median = 20 medications (range, 4-72). Those in the top quartile of medication use received ≥30 medications while in the NICU and had higher odds of being male sex, lower BW, longer length of hospital stay (LOHS), and bronchopulmonary dysplasia. Sepsis did not affect medication exposure. Antibiotics, opiates, and reflux medications were among the top prescribed.

CONCLUSION

Infants are exposed to a large number of medications during NICU hospitalization, including potentially unnecessary antibiotics and reflux medications. Male sex, the presence of certain comorbidities such as necrotizing enterocolitis, and LOHS, are associated with higher exposure. Increased awareness of this issue may assist in decreasing medication exposure in VLBW populations.

Cost of clinician-driven tests and treatments in very low birth weight and/or very preterm infants

OBJECTIVE

To rank clinician-driven tests and treatments (CTTs) by their total cost during the birth hospitalization for preterm infants.

STUDY DESIGN

Retrospective cohort of very low birth weight (<1500 g) and/or very preterm (<32 weeks) subjects admitted to US children's hospital Neonatal Intensive Care Units (2012-2018). CTTs were defined as pharmaceutical, laboratory and imaging services and ranked by total cost.

RESULTS

24,099 infants from 51 hospitals were included. Parenteral nutrition ($85M, 32% of pharmacy costs), blood gas analysis ($34M, 29% of laboratory costs), and chest radiographs ($18M, 31% of imaging costs) were the costliest CTTs overall. More than half of CTT-related costs occurred during 10% of hospital days.

CONCLUSIONS

The majority of CTT-related costs were from commonly used tests and treatments. Targeted efforts to improve value in neonatal care may benefit most from focusing on reducing unnecessary utilization of common tests and treatments, rather than infrequently used ones.

Decreasing Admissions to the NICU: An Official Transition Bed for Neonates

BACKGROUND

Evidence supports the need to decrease healthcare costs. One approach may be minimizing use of low-value care by reducing the number of unnecessary neonatal intensive care unit (NICU) admissions through the use of official neonatal transition beds.

PURPOSE

To evaluate whether transition beds decrease unnecessary NICU admissions and estimate the cost savings of this practice change.

METHODS

This retrospective chart review examined the records of all neonates of 350/7 weeks' gestational age and greater with birth weights of 2000 g and more admitted to a neonatal transition bed from January 1, 2017, to December 31, 2017. Outcomes evaluated were number of neonates returned to their mothers and an estimate of dollars saved for a 1-year period.

RESULTS

A total of 194 neonates were admitted to transition beds, which resulted in 144 NICU admissions averted. Respiratory distress was the most common reason for admission to transition beds. There was a statistically significant difference in length of stay in transition beds between neonates admitted to the NICU and those returned to couplet care after admission to transition beds (135.92 minutes vs 159.27 minutes; P = .047). There was no difference in gestational age based on admission to NICU or returned to couplet care (37.9 weeks vs 38 weeks; P = .772). The estimated cost savings was $3000 per neonate returned to couplet care totaling $432,000 annually.

IMPLICATIONS FOR PRACTICE

The use of neonatal transition beds is a potential strategy to decrease unnecessary NICU admissions and reduce low value care.

IMPLICATIONS FOR RESEARCH

Research regarding potential benefits of transition beds including the effect on hospital resources and low-value care at other institutions is needed. Additional research regarding potential benefits to the family including parent satisfaction and the effect of transition beds on rates of breastfeeding and skin-to-skin care is important.

Prioritization framework for improving the value of care for very low birth weight and very preterm infants

OBJECTIVE

Create a prioritization framework for value-based improvement in neonatal care.

STUDY DESIGN

A retrospective cohort study of very low birth weight (<1500 g) and/or very preterm (<32 weeks) infants discharged between 2012 and 2019 using the Pediatric Health Information System Database. Resource use was compared across hospitals and adjusted for patient-level differences. A prioritization score was created combining cost, patient exposure, and inter-hospital variability to rank resource categories.

RESULTS

Resource categories with the greatest cost, patient exposure, and inter-hospital variability were parenteral nutrition, hematology (lab testing), and anticoagulation (for central venous access and therapy), respectively. Based on our prioritization score, parenteral nutrition was identified as the highest priority overall.

CONCLUSIONS

We report the development of a prioritization score for potential value-based improvement in neonatal care. Our findings suggest that parenteral nutrition, central venous access, and high-volume laboratory and imaging modalities should be priorities for future comparative effectiveness and quality improvement efforts.