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Lee MH, Lee JH, Chang YS. Neonatologist staffing is related to the inter-hospital variation of risk-adjusted mortality of very low birth weight infants in Korea. Sci Rep 2024; 14:20959. [PMID: 39251660 PMCID: PMC11385627 DOI: 10.1038/s41598-024-69680-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 08/07/2024] [Indexed: 09/11/2024] Open
Abstract
This study investigated whether hospital factors, including patient volume, unit level, and neonatologist staffing, were associated with variations in standardized mortality ratios (SMR) adjusted for patient factors in very-low-birth-weight infants (VLBWIs). A total of 15,766 VLBWIs born in 63 hospitals between 2013 and 2020 were analyzed using data from the Korean Neonatal Network cohort. SMRs were evaluated after adjusting for patient factors. High and low SMR groups were defined as hospitals outside the 95% confidence limits on the SMR funnel plot. The mortality rate of VLBWIs was 12.7%. The average case-mix SMR was 1.1; calculated by adjusting for six significant patient factors: antenatal steroid, gestational age, birth weight, sex, 5-min Apgar score, and congenital anomalies. Hospital factors of the low SMR group (N = 10) had higher unit levels, more annual volumes of VLBWIs, more number of neonatologists, and fewer neonatal intensive care beds per neonatologist than the high SMR group (N = 13). Multi-level risk adjustment revealed that only the number of neonatologists showed a significant fixed-effect on mortality besides fixed patient risk effect and a random hospital effect. Adjusting for the number of neonatologists decreased the variance partition coefficient and random-effects variance between hospitals by 11.36%. The number of neonatologists was independently associated with center-to-center differences in VLBWI mortality in Korea after adjustment for patient risks and hospital factors.
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Affiliation(s)
- Myung Hee Lee
- Institute of Biomedical and Clinical Research, MEDITOS, Seoul, Republic of Korea
| | - Jang Hoon Lee
- Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Ku, Seoul, 06351, Korea.
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Korea.
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2
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Suenaga H, Nakanishi H, Uchiyama A, Kusuda S. Small for Gestational Age Affects Outcomes on Singletons and Inborn Births in Extremely Preterm Infants: A Japanese Cohort Study. Am J Perinatol 2024; 41:e780-e787. [PMID: 36041470 DOI: 10.1055/a-1933-4627] [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 This study aimed to compare the short- and long-term outcomes of extremely preterm small for gestational age (SGA) infants and appropriate for gestational age (AGA) infants in Japan. STUDY DESIGN We retrospectively assessed 434 SGA and 1,716 AGA infants born at 22 to 27 weeks of gestational age (GA) and examined their outcomes on singletons and inborn births between 2003 and 2012. Infants were followed-up for 3 years, and the clinical characteristics and outcomes were compared. Fisher's exact and Student's t-tests were used for independent sample comparison. Logistic regression was used to identify associated factors. RESULTS The prevalence of intraventricular hemorrhage ≥ grade 3 was significantly lower (adjusted odds ratio [aOR]: 0.28; 95% confidence interval [CI]: 0.11 - 0.72), and the prevalence of bronchopulmonary dysplasia at 36 weeks of GA and the need for home oxygen therapy were significantly higher (aOR: 2.20; 95% CI: 1.66 - 2.91 and aOR: 2.46; 95% CI: 1.75-3.47, respectively) in SGA infants than in AGA infants. SGA infants born at 24 to 25 weeks of GA had a significantly higher prevalence of developmental quotient (DQ) < 70 (aOR: 1.73; 95% CI: 1.08 - 2.77). Those born at 26 to 27 weeks of GA showed a significantly higher prevalence of cerebral palsy (CP) and visual impairment (aOR: 2.31; 95% CI: 1.22 - 4.40 and aOR: 2.61; 95% CI: 1.21 - 5.61, respectively). CONCLUSION In SGA infants, birth at 24 to 25 weeks of GA is an independent risk factor for DQ < 70, and birth at 26 to 27 weeks of GA is an independent risk factor for CP and visual impairment. However, we did not consider nutritional and developmental factors, and a longer follow-up would help assess neurodevelopmental outcomes. KEY POINTS · SGA is a risk factor for poor outcomes.. · In SGA infants, birth at 25 to 26 weeks is a risk factor for low a DQ.. · In SGA infants, birth at 26 to 27 weeks is a risk factor for CP..
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Affiliation(s)
- Hideyo Suenaga
- Department of pediatrics, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan
| | - Hidehiko Nakanishi
- Department of Advanced Medicine, Research and Development Center for New Medical Frontiers, Kanagawa, Japan
| | - Atsushi Uchiyama
- Department of Pediatrics, Tokai University School of Medicine, Kanagawa, Japan
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo, Japan
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3
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Li L, Du T, Zeng S. The Different Classification of Hospitals Impact on Medical Outcomes of Patients in China. Front Public Health 2022; 10:855323. [PMID: 35923962 PMCID: PMC9339675 DOI: 10.3389/fpubh.2022.855323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/02/2022] [Indexed: 11/26/2022] Open
Abstract
Background In China, different classification of hospitals (COH) provide treatment for patients with different degrees of illness. COH play an important role in Chinese medical outcomes, but there is a lack of quantitative description of how much impact the results have. The objective of this study is to examine the correlation between COH on medical outcomes with the hope of providing insights into appropriate care and resource allocation. Methods From the perspective of the COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with a sample size of 512,658 hospitalized patients, this study used the nested multinomial logit model (NMNL) to estimate the impact of COH on the medical outcomes. Results The patients were mainly elderly, with an average age of 66.28 years old. The average length of stay was 9.61 days. The female and male gender were split evenly. A high level of hospitals is positively and significantly associated with the death and transfer rates (p < 0.001), which may be related to more severe illness among patients in high COH. Conclusion The COH made a difference in the medical outcomes significantly. COH should be reasonably selected according to disease types to achieve the optimal medical outcome. So, China should promote the construction of a tiered delivery system.
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Affiliation(s)
- Lele Li
- School of Labor and Human Resources, Renmin University of China, Beijing, China
| | - Tiantian Du
- Research Office of Medical and Care Insurance, Chinese Academy of Labour and Social Security, Beijing, China
| | - Siyu Zeng
- School of Logistics, Chengdu University of Information Technology, Chengdu, China
- *Correspondence: Siyu Zeng
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4
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Mangiza M, Ehret DEY, Edwards EM, Rhoda N, Tooke L. Morbidity and mortality in small for gestational age very preterm infants in a middle-income country. Front Pediatr 2022; 10:915796. [PMID: 36016879 PMCID: PMC9396138 DOI: 10.3389/fped.2022.915796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/13/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To evaluate the impact of small for gestational age (SGA) on outcomes of very preterm infants at Groote Schuur Hospital (GSH), Cape Town, South Africa. STUDY DESIGN Data were obtained from the Vermont Oxford Network (VON) GSH database from 2012 to 2018. The study is a secondary analysis of prospectively collected observational data. Fenton growth charts were used to define SGA as birth weight < 10th centile for gestational age. RESULTS Mortality [28.9% vs. 18.5%, adjusted risk ratio (aRR) 2.1, 95% confidence interval (CI) 1.6-2.7], bronchopulmonary dysplasia (BPD; 14% vs. 4.5%, aRR 3.7, 95% CI 2.3-6.1), and late-onset sepsis (LOS; 16.7% vs. 9.6%, aRR 2.3, 95% CI 1.6-3.3) were higher in the SGA than in the non-SGA group. CONCLUSION Small for gestational age infants have a higher risk of mortality and morbidity among very preterm infants at GSH. This may be useful for counseling and perinatal management.
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Affiliation(s)
- Marcia Mangiza
- Groote Schuur Hospital, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Danielle E Y Ehret
- Vermont Oxford Network, Burlington, VT, United States.,Department of Paediatrics, Larner College of Medicine, University of Vermont, Burlington, VT, United States
| | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT, United States.,Department of Paediatrics, Larner College of Medicine, University of Vermont, Burlington, VT, United States.,Department of Mathematics and Statistics, University of Vermont, Burlington, VT, United States
| | - Natasha Rhoda
- Groote Schuur Hospital, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Groote Schuur Hospital, Department of Paediatrics, University of Cape Town, Cape Town, South Africa
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Neonatal Intensive Care Utilization and Postdischarge Newborn Outcomes: A Population-based Study of Texas Medicaid Insured Infants. J Pediatr 2021; 236:62-69.e3. [PMID: 33940013 DOI: 10.1016/j.jpeds.2021.04.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To test the hypothesis that newborn infants cared for in hospitals with greater utilization of neonatal intensive care experienced fewer postdischarge adverse events. STUDY DESIGN We developed 3 retrospective population-based cohorts of Texas Medicaid insured singletons born in 2010-2014 (very low birth weight [VLBW n = 11 139], late preterm [n = 57 509], and non-preterm [n = 664 447]) who received care in higher volume hospitals with level III/IV neonatal intensive care units (NICUs). Measures of NICU care were hospital-level risk adjusted NICU admission rates, special care days (days of nonroutine care) per infant, and the percent of intensive (highest billable care code) special care days. The units of analysis were hospitals (n = 80) and the primary outcome was an adverse event, (defined as admission, emergency department visit, or death) within 30 days postdischarge. RESULTS Higher use of NICU care at a hospital level was not associated with lower postdischarge 30-day adverse event. Infants cared for in hospitals with above vs below median special care day rates experienced slightly higher postdischarge adverse event per 100 infants (VLBW: 14.01 [95% CI 12.74-15.27] vs 11.84 [10.52-13.16], P < .05; late preterm: 7.33 [6.68-7.97] vs 6.28 [5.87-6.69], P < .01; non-preterm: 4.47 [4.17-4.76] vs 3.97 [3.75-4.18], P < .01). Weak positive associations (Pearson correlations of 0.31-0.37, P < .01) were observed for adverse event with special care days; in no instance was a negative association observed between NICU utilization and adverse event. CONCLUSION Higher utilization of NICU care was not associated with lower rates of short-term events suggesting that there may be opportunities to safely decrease admission rates and length of NICU stays.
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Azami M, Jasemi S, Khalifpur Y, Badfar G. Causes of mortality in a neonatal intensive care unit in Iran: one year data. MEDICAL JOURNAL OF INDONESIA 2020. [DOI: 10.13181/mji.oa.203449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Neonatal mortality rate is a major health index. Approximately, 65% of all deaths in the first year of life occur during this 4-week period. The present study was conducted to investigate the mortality rates and causes of death in a neonatal intensive care unit (NICU) in Ahvaz, Iran in a year.
METHODS This cross-sectional study was conducted in the NICU of Sina Hospital in Ahvaz. Medical records were studied, and data from 1,040 newborns admitted to the NICU within one year (March 2016 to March 2017) were collected following a checklist. Of these newborns, 123 died, and their relevant data were collected. Data were analyzed using SPSS, version 20 (SPSS Inc., USA).
RESULTS The mortality rate was 11.82% (123 cases) out of 1,040 newborns admitted to NICU. Most of the newborns (48.8%) died on days 1–7. The causes of death were respiratory distress syndrome (RDS) (34.1%), asphyxia (25.2%), anomalies (10.6%), sepsis (7.3%), intracerebral hemorrhage (8.1%), pulmonary hemorrhage (7.3%), and other causes (6.4%), such as hydrops, severe pneumothorax, severe renal failure, and others.
CONCLUSIONS The mortality rate in the NICU of this center was similar to that in other Iranian provinces. The most common causes of NICU mortality included prematurity and its complications, such as asphyxia and RDS. Thus, a strategic plan for reducing preterm delivery and asphyxia are necessary.
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Bonjorn Juarez M, Manrique Pons M, Grau Alcón L, Martinez-Momblan MA, Alonso-Fernández S. Reduction of visual and auditory stimuli to reduce pain during venipuncture in premature infants. Study protocol for a randomized controlled trial. J Adv Nurs 2019; 76:1077-1081. [PMID: 31865625 DOI: 10.1111/jan.14300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the efficacy of the reduction of visual and auditory stimuli on pain during venipuncture in premature newborns of 32-36 weeks of gestation. DESIGN Open, randomized, non-blind parallel clinical trial. METHOD Study to take place at the neonatal intensive care unit of a University Hospital in 2019-2021. Fifty-six recently born babies between 32-36 weeks of gestation will participate. The dependent variable is the level of pain determined using the premature infant pain profile instrument. The intervention will be assigned randomly using the random.org software. Data analysis will be carried out using the IBM SPSS v.25 software assuming a level of significance of 5%. DISCUSSION The evidence for the efficacy of reducing sensory stimulation and its effect on pain in minor procedures has not been studied in depth. There are no studies that evaluate the reduction of visual and auditory stimuli in a combined way. IMPACT It is easy to incorporate the reduction of visual and auditory stimuli into nursing practice. The results of this study could have a direct impact on clinical practice. Trial registered at clinicaltrials.gov: NCT04041635.
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Affiliation(s)
- Maria Bonjorn Juarez
- Catalan Institute of Health, Germans Trias i Pujol University Hospital. Ctra de Canyet s/n, Badalona, Spain.,IGTP, Health Sciences Research Institute Germans Trias I Pujol, Badalona, Spain
| | - Meritxell Manrique Pons
- Catalan Institute of Health, Germans Trias i Pujol University Hospital. Ctra de Canyet s/n, Badalona, Spain
| | - Laia Grau Alcón
- Catalan Institute of Health, Germans Trias i Pujol University Hospital. Ctra de Canyet s/n, Badalona, Spain
| | - María Antonia Martinez-Momblan
- Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, University of Barcelona, Pavelló de Govern, Barcelona, Spain
| | - Sergio Alonso-Fernández
- Catalan Institute of Health, Germans Trias i Pujol University Hospital. Ctra de Canyet s/n, Badalona, Spain.,Fundamental Care and Medical-Surgical Nursing Department, School of Nursing, University of Barcelona, Pavelló de Govern, Barcelona, Spain.,Avinguda de la Granvia, IDIBELL, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain
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8
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Spotswood N, Orsini F, Dargaville P. Association of Center-Specific Patient Volumes and Early Respiratory Management Practices with Death and Bronchopulmonary Dysplasia in Preterm Infants. J Pediatr 2019; 210:63-68.e2. [PMID: 31005279 DOI: 10.1016/j.jpeds.2019.02.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/05/2019] [Accepted: 02/26/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe variability in admission volumes and approach to early respiratory support between neonatal intensive care units in the Australian and New Zealand Neonatal Network and to evaluate whether these center-specific factors are associated with death and bronchopulmonary dysplasia. STUDY DESIGN This retrospective cohort study included 19 099 neonates born between 25 and 32 weeks' gestation and admitted to 1 of 25 NICUs from 2007 to 2013. Center-specific factors evaluated were annual admission volume and rate of using continuous positive airway pressure (CPAP) rather than intubation as the first mode of respiratory support. Logistic regression was used to examine any association of these center-specific factors with death, BPD, and death or survival with BPD (death/BPD). Analysis was performed separately for 2 gestation groups (25-28 weeks and 29-32 weeks inclusive). RESULTS Admission volumes and rates of early CPAP use varied widely across centers. Higher admission volumes were associated with lower odds of death or survival with BPD in the 25-28 week group (aOR 0.93, 99% CI 0.88-0.99 per increase of 10 babies per center annually). Centers with higher early CPAP use did not have lower odds of death or BPD than centers that intubated more frequently. CONCLUSIONS Higher admission volumes are associated with more favorable outcomes for the more preterm infants in the Australian and New Zealand Neonatal Network. Further investigation is required to explore why the individual benefits of early CPAP do not translate to better outcomes for centers that use this approach most frequently.
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Affiliation(s)
- Naomi Spotswood
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Burnet Institute, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Trials Center, Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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9
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Altimier L, Phillips R. Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth. Crit Care Nurs Clin North Am 2019; 30:563-583. [PMID: 30447814 DOI: 10.1016/j.cnc.2018.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.
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Affiliation(s)
- Leslie Altimier
- Northeastern University, School of Nursing in the Bouvé College of Health Sciences, 360 Huntington Avenue, Boston, MA 02115, USA; Philips HealthTech, Cambridge, MA, USA.
| | - Raylene Phillips
- Loma Linda University School of Medicine, Department of Pediatrics, Division of Neonatology, Loma Linda University Children's Hospital, 11175 Campus Street, CP 11121 Loma Linda, CA 92354, USA; Loma Linda University Medical Center-Murrieta, 28062 Baxtor Road, Murrieta, CA 92563, USA
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10
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Abdel-Latif ME, Nowak G, Bajuk B, Glass K, Harley D. Variation in hospital mortality in an Australian neonatal intensive care unit network. Arch Dis Child Fetal Neonatal Ed 2018; 103:F331-F336. [PMID: 29074720 PMCID: PMC6047145 DOI: 10.1136/archdischild-2017-313222] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Studying centre-to-centre (CTC) variation in mortality rates is important because inferences about quality of care can be made permitting changes in practice to improve outcomes. However, comparisons between hospitals can be misleading unless there is adjustment for population characteristics and severity of illness. OBJECTIVE We sought to report the risk-adjusted CTC variation in mortality among preterm infants born <32 weeks and admitted to all eight tertiary neonatal intensive care units (NICUs) in the New South Wales and the Australian Capital Territory Neonatal Network (NICUS), Australia. METHODS We analysed routinely collected prospective data for births between 2007 and 2014. Adjusted mortality rates for each NICU were produced using a multiple logistic regression model. Output from this model was used to construct funnel plots. RESULTS A total of 7212 live born infants <32 weeks gestation were admitted consecutively to network NICUs during the study period. NICUs differed in their patient populations and severity of illness.The overall unadjusted hospital mortality rate for the network was 7.9% (n=572 deaths). This varied from 5.3% in hospital E to 10.4% in hospital C. Adjusted mortality rates showed little CTC variation. No hospital reached the +99.8% control limit level on adjusted funnel plots. CONCLUSION Characteristics of infants admitted to NICUs differ, and comparing unadjusted mortality rates should be avoided. Logistic regression-derived risk-adjusted mortality rates plotted on funnel plots provide a powerful visual graphical tool for presenting quality performance data. CTC variation is readily identified, permitting hospitals to appraise their practices and start timely intervention.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, Australian Capital Territory, Australia,Discipline of Neonatology, Medical School, College of Medicine, Biology & Environment, Australian National University, Woden ACT, Australian Capital Territory, Australia
| | - Gen Nowak
- Research School of Finance, Actuarial Studies and Statistics, College of Business and Economics, Australian National University, Acton, Australian Capital Territory, Australia
| | - Barbara Bajuk
- NSW Pregnancy and Newborn Services Network, Sydney Children’s Hospitals Network, Randwick, New South Wales, Australia
| | - Kathryn Glass
- Research School of Population Health and Medical School, Australian National University, Acton, Australian Capital Territory, Australia
| | - David Harley
- Research School of Population Health and Medical School, Australian National University, Acton, Australian Capital Territory, Australia,Queensland Centre for Intellectual and Developmental Disability (QCIDD), Mater Research Institute, University of Queensland, South Brisbane, Queensland
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11
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Bekelis K, Missios S, Coy S, MacKenzie TA. Association of Hospital Teaching Status with Neurosurgical Outcomes: An Instrumental Variable Analysis. World Neurosurg 2017; 110:e689-e698. [PMID: 29174238 DOI: 10.1016/j.wneu.2017.11.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND The interpretation of the results of prior studies on the association of hospital teaching status with surgical outcomes is limited by selection bias. We investigated whether undergoing surgical operations in teaching hospitals is associated with improved outcomes. METHODS We performed a cohort study of all patients undergoing spine and cranial operations who were registered in the New York Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of teaching status (defined as academic affiliation for the primary analysis) with inpatient case fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and to simulate the effect of a randomized trial. RESULTS During the study period, 186,483 patients underwent surgical operations that met the inclusion criteria. Instrumental variable analysis demonstrated that hospitalization in teaching hospitals was associated with higher rates of case fatality (adjusted difference, 25%; 95% confidence interval [CI], 4%-46%), discharge to a facility (adjusted difference, 5.7%; 95% CI, 4.5%-7.0%), and longer LOS (adjusted difference, 31.4%; 95% CI, 16.0%-46.1%) in comparison with nonteaching hospitals. The same associations were present in propensity score adjusted mixed effects models. These persisted in prespecified subgroups stratified on particular operations and for different definitions of teaching hospitals. CONCLUSIONS Using a comprehensive all-payer cohort of surgical patients in New York State, we identified an association of treatment in teaching hospitals with increased case fatality, rate of discharge to rehabilitation, and longer LOS. Further research into the factors contributing to superior outcomes in nonteaching institutions is warranted.
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Affiliation(s)
- Kimon Bekelis
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA; The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Population Health Research Institute of New York at CHS, Melville, New York, USA; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
| | - Symeon Missios
- Center for Neuro and Spine, Akron General - Cleveland Clinic, Akron, Ohio, USA
| | - Shannon Coy
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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12
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Tawfik DS, Sexton JB, Adair KC, Kaplan HC, Profit J. Context in Quality of Care: Improving Teamwork and Resilience. Clin Perinatol 2017; 44:541-552. [PMID: 28802338 PMCID: PMC5644508 DOI: 10.1016/j.clp.2017.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Quality improvement in health care is an ongoing challenge. Consideration of the context of the health care system is of paramount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown that teamwork and burnout relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.
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Affiliation(s)
- Daniel S Tawfik
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, 770 Welch Road, Suite 435, Stanford, CA 94304, USA; Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA 94304, USA.
| | - J Bryan Sexton
- Department of Psychiatry, Duke University School of Medicine; Duke University Health System, Durham, NC, USA,Duke Patient Safety Center, Duke University Health System, Durham, NC, USA
| | - Kathryn C Adair
- Department of Psychiatry, Duke University School of Medicine; Duke University Health System, Durham, NC, USA,Duke Patient Safety Center, Duke University Health System, Durham, NC, USA
| | - Heather C Kaplan
- Department of Pediatrics, Perinatal Institute, James M. Anderson Centre for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center
| | - Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital; Palo Alto, CA, USA,California Perinatal Quality Care Collaborative; Palo Alto, CA, USA
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13
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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: 111] [Impact Index Per Article: 15.9] [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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14
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Darlow BA, Lui K, Kusuda S, Reichman B, Håkansson S, Bassler D, Modi N, Lee SK, Lehtonen L, Vento M, Isayama T, Sjörs G, Helenius KK, Adams M, Rusconi F, Morisaki N, Shah PS. International variations and trends in the treatment for retinopathy of prematurity. Br J Ophthalmol 2017; 101:1399-1404. [PMID: 28270489 DOI: 10.1136/bjophthalmol-2016-310041] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/19/2017] [Accepted: 02/10/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To compare the rates of retinopathy of prematurity (ROP) and treatment of ROP by laser or intravitreal anti-vascular endothelial growth factor among preterm neonates from high-income countries participating in the International Network for Evaluating Outcomes (iNeo) of neonates. METHODS A retrospective cohort study was conducted on extremely preterm infants weighing <1500 g at 240 to 276 weeks' gestation who were admitted to neonatal units in Australia/New Zealand, Canada, Finland, Israel, Japan, Spain, Sweden, Switzerland, Tuscany (Italy) and the UK between 2007 and 2013. Pairwise comparisons of ROP treatment in survivors between countries were evaluated by Poisson and multivariable logistic regression analyses after adjustment for confounders. A composite outcome of death or ROP treatment was compared between countries using logistic regression and standardised ratios. RESULTS Of 48 087 infants included in the analysis, 81.8% survived to 32 weeks postmenstrual age, and 95% of survivors were screened for ROP. Rates of any ROP ranged from 25.2% to 91.0% in Switzerland and Japan, respectively, among those examined. The overall rate of those receiving treatment was 24.9%, which varied from 4.3% to 30.4%. Adjusted risk ratios for ROP treatment were lower for Switzerland in all pairwise comparisons, whereas Japan displayed significantly higher ratios. Comparisons of the composite outcome between countries revealed similar, but less marked differences. CONCLUSIONS Rates of any ROP and ROP treatment varied significantly between iNeo members, while an overall decline in ROP treatment was observed during the study period. It is unclear whether these variations represent differences in care practices, diagnosis and/or treatment thresholds.
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Affiliation(s)
- Brian A Darlow
- Australia and New Zealand Neonatal Network, Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Kei Lui
- Australian and New Zealand Neonatal Network, Royal Hospital for Women, National Perinatal Epidemiology and Statistic Unit, University of New South Wales, Randwick, Australia
| | - Satoshi Kusuda
- Neonatal Research Network Japan, Maternal and Perinatal Center, Tokyo Women's Medical University, Kawadacho, Shinjuku, Tokyo, Japan
| | - Brian Reichman
- Israel Neonatal Network, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Centre, Tel Hashomer, Israel
| | - Stellan Håkansson
- Swedish Neonatal Quality Register, Department of Pediatrics/Neonatal Services, Umeå University Hospital, Umeå, Sweden
| | - Dirk Bassler
- Swiss Neonatal Network, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, Zurich, Switzerland
| | - Neena Modi
- UK Neonatal Collaborative, Neonatal Data Analysis Unit, Section of Neonatal Medicine, Department of Medicine, Imperial College London, Chelsea and Westminster Hospital campus, London, UK
| | - Shoo K Lee
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.,Canadian Neonatal Network, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Liisa Lehtonen
- Finnish Medical Birth Register and Register of Congenital Malformations, Department of Pediatrics, Turku Univeristy Hospital, Kiinamyllynkatu, Turku, Finland
| | - Maximo Vento
- Spanish Neonatal Network, Health Research Institute La Fe, Avenida Fernando Abril Martorell, Valencia, Spain
| | - Tetsuya Isayama
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Gunnar Sjörs
- Swedish Neonatal Quality Register, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Kjell K Helenius
- Finnish Medical Birth Register and Register of Congenital Malformations, Department of Pediatrics, Turku Univeristy Hospital, Kiinamyllynkatu, Turku, Finland
| | - Mark Adams
- Swiss Neonatal Network, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse, Zurich, Switzerland
| | - Franca Rusconi
- TIN Toscane Online, Unit of Epidemiology, Meyer Children's University Hospital, Viale Pieraccini, Florence, Italy.,Regional Health Agency, Via Pietro Dazzi, Florence, Italy
| | - Naho Morisaki
- Neonatal Research Network Japan, Department of Social Medicine, National Center for Child Health and Development, Okura, Setagaya, Tokyo, Japan
| | - Prakesh S Shah
- Department of Paediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.,Canadian Neonatal Network, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada
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15
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Rochow N, Landau-Crangle E, Lee S, Schünemann H, Fusch C. Quality Indicators but Not Admission Volumes of Neonatal Intensive Care Units Are Effective in Reducing Mortality Rates of Preterm Infants. PLoS One 2016; 11:e0161030. [PMID: 27508499 PMCID: PMC4980039 DOI: 10.1371/journal.pone.0161030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/28/2016] [Indexed: 11/19/2022] Open
Abstract
AIM To investigate how two different strategies to form larger neonatal intensive care units (NICU) impact neonatal mortality rates. METHODS Cross-sectional study modeling admission volumes and mortality rates of 177,086 VLBW infants aggregated into 862 NICUs. Cumulative 3-year data was abstracted from Vermont Oxford Network. The model simulated a reduction in number of NICUs by stepwise exclusion using either admission volume (VOL) or quality (QUAL) cut-offs. After randomly redirecting infants of excluded to remaining NICUs resulting system mortality rates were calculated with and without adjusting for effects of experience levels (EL) using published data to reflect effects of different team-to-patient exposure. RESULTS The quality-based strategy is more effective in reducing mortality; while VOL alone was not able to reduce system mortality, QUAL already achieved a 5% improvement after reducing 8% of NICUs and redirecting 6% of infants. Including "EL", a 5% improvement of mortality was achieved by reducing 77% (VOL) vs. 7% (QUAL) of NICUs and redirecting 54% (VOL) vs. 5% (QUAL) of VLBW infants, respectively. CONCLUSION While a critical number of admissions is needed to maintain skills this study emphasizes the importance of including quality parameters to restructure neonatal care. The findings can be generalized to other medical fields.
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Affiliation(s)
- Niels Rochow
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Erin Landau-Crangle
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Sauyoung Lee
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Holger Schünemann
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Christoph Fusch
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Canada
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16
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Hornik CP, Sherwood AL, Cotten CM, Laughon MM, Clark RH, Smith PB. Daily mortality of infants born at less than 30weeks' gestation. Early Hum Dev 2016; 96:27-30. [PMID: 27018746 PMCID: PMC4862884 DOI: 10.1016/j.earlhumdev.2016.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 01/13/2016] [Accepted: 03/01/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies have reported odds of mortality for hospitalized premature infants stratified by postnatal age and adjusted for severity of illness. Our objective was to examine day-by-day mortality of premature infants in a large multicenter cohort of infants, adjusted for demographics, severity of illness, and receipt of therapeutic interventions. METHODS This was a multicenter cohort study of infants cared for in 362 neonatal intensive care units with a shared clinical data warehouse from 1997 to 2013. We included all inborn infants born at 22-29weeks' gestational age with available mortality discharge data. We report the point prevalence of survival to hospital discharge stratified by gestational and postnatal age. RESULTS We identified 64,896 infants, of whom 55,348 (85%) survived to hospital discharge. Survival increased with gestational and postnatal age, until infants reached a postmenstrual age of approximately 37weeks, after which survival began to decrease. Overall survival increased over time (80% in 1997 to 88% in 2013, P<.001). CONCLUSIONS Given the known association between gestational age and postnatal age, survival predictions should be adjusted for both covariates.
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Affiliation(s)
- Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Ashley L Sherwood
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, United States
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States.
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18
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Abstract
Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.
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Affiliation(s)
- Jochen Profit
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA, USA; California Perinatal Quality Care Collaborative, Palo Alto, CA, USA.
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA; Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA
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19
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Chow S, Chow R, Popovic M, Lam M, Popovic M, Merrick J, Stashefsky Margalit RN, Lam H, Milakovic M, Chow E, Popovic J. A Selected Review of the Mortality Rates of Neonatal Intensive Care Units. Front Public Health 2015; 3:225. [PMID: 26501049 PMCID: PMC4595739 DOI: 10.3389/fpubh.2015.00225] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Newborn babies in need of critical medical attention are normally admitted to the neonatal intensive care unit (NICU). These infants tend to be preterm, have low birth weight, and/or have serious medical conditions. Neonatal survival varies, but progress in perinatal and neonatal care has notably diminished mortality rates. In this selected review, we examine and compare the NICU mortality rates and etiologies of death in different countries. METHODS A literature search was conducted in Ovid MEDLINE, OLDMEDLINE, EMBASE Classic, and EMBASE. The primary endpoint was the mortality rates in NICUs. Secondary endpoints included the reasons for death and the correlation between infant age and mortality outcome. For the main analysis, we examined all infants admitted to NICUs. Subgroup analyses included extremely low birth weight infants (based on the authors' own definition), very low birth weight infants, very preterm infants, preterm infants, preterm infants with a birth weight of ≤1,500 g, and by developed and developing countries. RESULTS The literature search yielded 1,865 articles, of which 20 were included. The total mortality rates greatly varied among countries. Infants in developed and developing countries had similar ages at death, ranging from 4 to 20 days and 1 to 28.9 days, respectively. The mortality rates ranged from 4 to 46% in developed countries and 0.2 to 64.4% in developing countries. CONCLUSION The mortality rates of NICUs vary between nations but remain high in both developing and developed countries.
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Affiliation(s)
- Selina Chow
- Toronto East General Hospital , Toronto, ON , Canada
| | - Ronald Chow
- Toronto East General Hospital , Toronto, ON , Canada
| | - Mila Popovic
- Toronto East General Hospital , Toronto, ON , Canada
| | - Michael Lam
- Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | - Marko Popovic
- Toronto East General Hospital , Toronto, ON , Canada
| | - Joav Merrick
- Health Services, Division for Intellectual and Developmental Disabilities, National Institute of Child Health and Human Development, Ministry of Social Affairs , Jerusalem , Israel
| | - Ruth Naomi Stashefsky Margalit
- MSR Israel Center for Medical Simulation, Chaim Sheba Medical Center, Tel Hashomer National Education Center , Ramat Gan , Israel
| | - Henry Lam
- Sunnybrook Health Sciences Centre , Toronto, ON , Canada
| | | | - Edward Chow
- Sunnybrook Health Sciences Centre , Toronto, ON , Canada
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20
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Morris M, Cleary JP, Soliman A. Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants. Pediatrics 2015; 136:e1007-15. [PMID: 26347427 DOI: 10.1542/peds.2014-3918] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The survival rates for extremely low birth weight (ELBW) infants have improved, but many are discharged from the hospital with significant challenges. Our goal was to improve outcomes for this population by using a multidisciplinary team-based quality improvement approach. METHODS A unique program called the Small Baby Unit (SBU) was established in a children's hospital to care for the ELBW infant born at 28 weeks or less and weighing less than 1000 g at birth. These patients were cared for in a separate location from the main neonatal unit. A core multidisciplinary team that participates in ongoing educational and process-improvement collaboration provides care. Evidence-based guidelines and checklists standardized the approach. RESULTS Data from the 2 years before and 4 years after opening the SBU are included. There was a reduction in chronic lung disease from 47.5% to 35.4% (P = .097). The rate of hospital-acquired infection decreased from 39.3% to 19.4% (P < .001). Infants being discharged with growth restriction (combined weight and head circumference <10th percentile) decreased from 62.3% to 37.3% (P = .001). Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 (P < .001) and radiographs decreased from 45 to 22 (P < .001). CONCLUSIONS Care in a distinct unit by a consistent multidisciplinary SBU team using quality improvement methods improved outcomes in ELBW infants. Ongoing team engagement and development are required to sustain improved outcomes.
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Affiliation(s)
- Mindy Morris
- Division of Neonatology, CHOC Children's Hospital, Orange, California; and
| | | | - Antoine Soliman
- Miller Children's and Women's Hospital, Long Beach, California
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21
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Steurer MA, Adams M, Bacchetti P, Schulzke SM, Roth‐Kleiner M, Berger TM. Swiss medical centres vary significantly when it comes to outcomes of neonates with a very low gestational age. Acta Paediatr 2015; 104:872-9. [PMID: 26014127 PMCID: PMC4744957 DOI: 10.1111/apa.13047] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 04/06/2015] [Accepted: 05/19/2015] [Indexed: 11/30/2022]
Abstract
Aim This study quantified the impact of perinatal predictors and medical centre on the outcome of very low‐gestational‐age neonates (VLGANs) born at <32 completed weeks in Switzerland. Methods Using prospectively collected data from a 10‐year cohort of VLGANs, we developed logistic regression models for three different time points: delivery, NICU admission and seven days of age. The data predicted survival to discharge without severe neonatal morbidity, such as major brain injury, moderate or severe bronchopulmonary dysplasia, retinopathy of prematurity (≥stage three) or necrotising enterocolitis (≥stage three). Results From 2002 to 2011, 6892 VLGANs were identified: 5854 (85%) of the live‐born infants survived and 84% of the survivors did not have severe neonatal complications. Predictors for adverse outcome at delivery and on NICU admission were low gestational age, low birthweight, male sex, multiple birth, birth defects and lack of antenatal corticosteroids. Proven sepsis was an additional risk factor on day seven of life. The medical centre remained a statistically significant factor at all three time points after adjusting for perinatal predictors. Conclusion After adjusting for perinatal factors, the survival of Swiss VLGANs without severe neonatal morbidity was strongly influenced by the medical centre that treated them.
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Affiliation(s)
- Martina A. Steurer
- Division of Pediatric Critical Care UCSF Medical Centre San Francisco CA USA
| | - Mark Adams
- Department of Neonatology University Hospital of Zurich Zurich Switzerland
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics UCSF San Francisco CA USA
| | - Sven M. Schulzke
- Department of Neonatology University Children's Hospital Basel Basel Switzerland
| | - Matthias Roth‐Kleiner
- Clinic of Neonatology University Hospital and University of Lausanne Lausanne Switzerland
| | - Thomas M. Berger
- Neonatal and Paediatric Intensive Care Unit Children's Hospital of Lucerne Lucerne Switzerland
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22
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Shah PS, Mirea L, Ng E, Solimano A, Lee SK. Association of unit size, resource utilization and occupancy with outcomes of preterm infants. J Perinatol 2015; 35:522-9. [PMID: 25675049 DOI: 10.1038/jp.2015.4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/28/2014] [Accepted: 12/17/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Assess association of NICU size, and occupancy rate and resource utilization at admission with neonatal outcome. STUDY DESIGN Retrospective cohort study of 9978 infants born at 23-32 weeks gestation and admitted to 23 tertiary-level Canadian NICUs during 2010-2012. Adjusted odds ratios (AOR) were estimated for a composite outcome of mortality/any major morbidity with respect to NICU size, occupancy rate and intensity of resource utilization at admission. RESULTS A total of 2889 (29%) infants developed the composite outcome, the odds of which were higher for 16-29, 30-36 and >36-bed NICUs compared with <16-bed NICUs (AOR (95% CI): 1.47 (1.25-1.73); 1.49 (1.25-1.78); 1.55 (1.29-1.87), respectively) and for NICUs with higher resource utilization at admission (AOR: 1.30 (1.08-1.56), Q4 vs Q1) but not different according to NICU occupancy. CONCLUSION Larger NICUs and more intense resource utilization at admission are associated with higher odds of a composite adverse outcome in very preterm infants.
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Affiliation(s)
- P S Shah
- 1] Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada [2] Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - L Mirea
- 1] Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada [2] Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - E Ng
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - A Solimano
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - S K Lee
- 1] Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada [2] Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Murki S, Kumar N, Chawla D, Bansal A, Mehta A, Shah M, Bhat S, Rao S, Bajaj N, Chowdhary G, Singal A, Kadam S, Jain N, Baswaraj T, Thakre R. Variability in survival of very low birth weight neonates in hospitals of India. Indian J Pediatr 2015; 82:565-7. [PMID: 25689961 DOI: 10.1007/s12098-015-1714-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 01/22/2015] [Indexed: 11/30/2022]
Abstract
This prospective cohort study was conducted to evaluate variability in mortality of very low birth weight (VLBW) neonates during their birth hospitalization in different hospitals of India. A liveborn neonate was eligible for inclusion in the study if it was born or admitted in a participating hospital between 1st January and 31st December 2012 and weighed 1500g or less at birth. Neonates were given clinical care as per standard protocols. Standardized neonatal mortality ratio (SNMR) was calculated as the ratio of the observed mortality to the expected mortality. Expected mortality rate for each unit was calculated by adjusting for various prognostic factors at the time of birth or admission in the participating unit. Among 1345 neonates [mean birth weight: 1168 ± 240g, median gestation: 30wk (IQR: 28-32)] enrolled in the study 199 (14.8%) died before hospital discharge. Although variation in inter-hospital SNMR was statistically insignificant (P 0.49), 95% CI of SNMR of most hospitals was broad reaching level of clinical significance on both sides of line of equivalence. This indicates the need to establish an ongoing quality-improvement collaborative network to identify and adopt clinical practices associated with decreased mortality.
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Trevisanuto D, Satariano I, Doglioni N, Criscoli G, Cavallin F, Gizzi C, Martano C, Ciralli F, Torielli F, Villani PE, Di Fabio S, Quartulli L, Giannini L. Delivery room management of extremely low birthweight infants shows marked geographical variations in Italy. Acta Paediatr 2014; 103:605-11. [PMID: 24606020 DOI: 10.1111/apa.12612] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 02/06/2014] [Accepted: 02/20/2014] [Indexed: 01/21/2023]
Abstract
AIM To evaluate any geographical variations in practice and adherence to international guidelines for early delivery room management of extremely low birthweight (ELBW) infants in the North, Centre and South of Italy. METHODS A questionnaire was sent to all 107 directors of Italian level III centres between April and August 2012. RESULTS There was a 92% (n = 98) response rate. A polyethylene bag/wrap was used by 54 centres (55.1%), with the highest rate in Northern Italy (77.5%) and the lowest rate in Southern (37.7%) areas. In Northern regions, one centre (2.5%) said it used oxygen concentrations >40% to initiate positive pressure ventilation in ELBW infants. These proportions were higher in the Central (14.3%) and Southern (16.2%) areas. A T-piece device for positive pressure ventilation was more frequently available in the Northern (95%) units than in those in the Central (66.7%) and Southern (69.4%) regions. A median of 13% (IQR: 5%-30%) of ELBW infants received chest compressions at birth in Italy: 5%, 18% and 22% in Northern, Central and Southern units, respectively. CONCLUSION In Italy, delivery room management of ELBW infants showed marked geographical variations. Implementation of national training programmes could increase adherence to the guidelines and reduce such discordance.
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Affiliation(s)
- Daniele Trevisanuto
- Children and Women's Health Department; Medical School University of Padua Azienda; Padua Italy
| | - Irene Satariano
- Children and Women's Health Department; Medical School University of Padua Azienda; Padua Italy
| | - Nicoletta Doglioni
- Children and Women's Health Department; Medical School University of Padua Azienda; Padua Italy
| | - Giulio Criscoli
- Italian Army - Signals and Information Technology HQ - C4 Systems Integration Development; Treviso Italy
| | | | - Camilla Gizzi
- Neonatal Intensive Care Unit Pediatric; Neonatal Department ‘S.Giovanni Calibita’; Fatebenefratelli Hospital; Rome Italy
| | - Claudio Martano
- Neonatal Intensive Care Unit; Pediatric Department; Medical School University of Turin; Azienda Ospedaliera OIRM-S; Torino Italy
| | - Fabrizio Ciralli
- Neonatal Intensive Care Unit; Department of Mother and Infant Science Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - Flaminia Torielli
- Neonatology Unit; University of Genova; Azienda Ospedaliera San Martino IRCCS - IST National Institute on Cancer Research; Genova Italy
| | - Paolo E. Villani
- Neonatal Intensive Care Unit; Maternal and Pediatric Department; Carlo Poma Hospital; Mantova Italy
| | - Sandra Di Fabio
- Neonatal Intensive Care Unit; Department of Mother and Infant Science; ‘San Salvatore’ Hospital; L'Aquila Italy
| | | | - Luigi Giannini
- Pediatric Department; Medical School University ‘La Sapienza’ Rome Azienda Ospedaliera Policlinico Umberto; Rome Italy
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Corvaglia L, Fantini MP, Aceti A, Gibertoni D, Rucci P, Baronciani D, Faldella G. Predictors of full enteral feeding achievement in very low birth weight infants. PLoS One 2014; 9:e92235. [PMID: 24647523 PMCID: PMC3960219 DOI: 10.1371/journal.pone.0092235] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 02/20/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To elucidate the role of prenatal, neonatal and early postnatal variables in influencing the achievement of full enteral feeding (FEF) in very low birth weight (VLBW) infants and to determine whether neonatal intensive care units (NICUs) differ in this outcome. METHODS Population-based retrospective cohort study using data on 1,864 VLBW infants drawn from the "Emilia-Romagna Perinatal Network" Registry from 2004 to 2009. The outcome of interest was time to FEF achievement. Eleven prenatal, neonatal and early postnatal variables and the study NICUs were selected as potential predictors of time to FEF. Parametric survival analysis was used to model time to FEF as a function of the predictors. Marginal effects were used to obtain adjusted estimates of median time to FEF for specific subgroups of infants. RESULTS Lower gestational age, exclusive formula feeding, higher CRIB II score, maternal hypertension, cesarean delivery, SGA and PDA predicted delayed FEF. NICUs proved to be heterogeneous in terms of FEF achievement. Newborns with PDA had a 4.2 days longer predicted median time to FEF compared to those without PDA; newborns exclusively formula-fed had a 1.4 days longer time to FEF compared to those fed human milk. CONCLUSIONS The results of our study suggest that time to FEF is influenced by clinical variables and NICU-specific practices. Knowledge of the variables associated with delayed/earlier FEF achievement could help in improving specific aspects of routine clinical management of VLBW infants and to reduce practice variability.
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Affiliation(s)
- Luigi Corvaglia
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Arianna Aceti
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Dino Gibertoni
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Dante Baronciani
- Servizio Presidi Ospedalieri, Direzione Generale Sanità e Politiche Sociali, Regione Emilia-Romagna, Bologna, Italy
| | - Giacomo Faldella
- Neonatology and Neonatal Intensive Care Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Kozhimannil KB, Hung P, Prasad S, Casey M, McClellan M, Moscovice IS. Birth volume and the quality of obstetric care in rural hospitals. J Rural Health 2014; 30:335-43. [PMID: 24483138 DOI: 10.1111/jrh.12061] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and hospitals in rural areas. METHODS The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in rural hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration). RESULTS The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume rural hospitals compared with low-volume hospitals after controlling for maternal demographic and clinical factors. In low-volume hospitals, odds of labor induction without medical indication were higher than in medium-volume hospitals, but not significantly different from medium-high or high-volume hospitals. Odds of episiotomy were greater in medium-high or high-volume hospitals than in low-volume hospitals. The likelihood of perineal laceration did not differ significantly by birth volume. CONCLUSIONS Obstetric quality and safety outcomes vary significantly across rural hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.
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Affiliation(s)
- Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, Minnesota; University of Minnesota Rural Health Research Center, Minneapolis, Minnesota
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Lehtonen L. Bringing transparency into quality comparison research. Acta Paediatr 2014; 103:19-21. [PMID: 24148182 DOI: 10.1111/apa.12480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Liisa Lehtonen
- Turku University Hospital; Turku University; Turku Finland
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Lapillonne A, Carnielli VP, Embleton ND, Mihatsch W. Quality of newborn care: adherence to guidelines for parenteral nutrition in preterm infants in four European countries. BMJ Open 2013; 3:e003478. [PMID: 24052611 PMCID: PMC3780296 DOI: 10.1136/bmjopen-2013-003478] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/15/2013] [Accepted: 08/16/2013] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The level of adherence to guidelines should be explored particularly in preterm infants for whom poor nutrition has major effects on outcomes in later life. The objective was to evaluate compliance to international guidelines for parenteral nutrition (PN) in preterm infants across neonatal intensive care units (NICUs) of four European countries. DESIGN Clinical practice survey by means of a questionnaire addressing routine PN protocols, awareness and implementation of guidelines. SETTING NICUs in the UK, Italy, Germany and France. PARTICIPANTS One senior physician per unit; 199 units which represent 74% of the NICUs of the four countries. PRIMARY OUTCOME MEASURE Adherence of unit protocol to international guidelines. SECONDARY OUTCOME MEASURE Factors that influence adherence to guidelines. RESULTS 80% of the respondents stated that they were aware of some PN clinical practice guidelines. For amino acid infusion (AA), 63% of the respondents aimed to initiate AA on D0, 38% aimed to administer an initial dose ≥1.5 g/kg/day and 91% aimed for a target dose of 3 or 4 g/kg/day, as recommended. For parenteral lipids, 90% of the respondents aimed to initiate parenteral lipids during the first 3 days of life, 39% aimed to use an initial dose ≥1.0 g/kg/day and 76% defined the target dose as 3-4 g/kg/day, as recommended. Significant variations in PN protocols were observed among countries, but the type of hospital or the number of admissions per year had only a marginal impact on the PN protocols. CONCLUSIONS Most respondents indicated that their clinical practice was based on common guidelines. However, the initiation of PN is frequently not compliant with current recommendations, with the main differences being observed during the first days of life. Continuous education focusing on PN practice is needed, and greater efforts are required to disseminate and implement international guidelines.
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Affiliation(s)
- Alexandre Lapillonne
- Department of Neonatal Medicine, Paris Descartes University, APHP Necker Hospital, Paris, France
- CNRC, Baylor College of Medicine, Houston, Texas, USA
| | - Virgilio Paolo Carnielli
- Division of Neonatology, Department of Clinical Sciences, Polytechnic University of Marche and Salesi's Children Hospital, Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy
| | - Nicholas David Embleton
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Walter Mihatsch
- Department of Neonatology, Pediatric Clinic Harlaching, Munich, Germany
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Mosqueda R, Castilla Y, Perapoch J, Lora D, López-Maestro M, Pallás C. Necessary resources and barriers perceived by professionals in the implementation of the NIDCAP. Early Hum Dev 2013; 89:649-53. [PMID: 23701747 DOI: 10.1016/j.earlhumdev.2013.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 04/19/2013] [Accepted: 04/23/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND The implementation of the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) requires a significant effort from all professionals involved. AIM To determine the necessary requirements and barriers perceived by health professionals in the implementation of the NIDCAP. STUDY DESIGN A questionnaire covering requirements and obstacles perceived in the implementation of the NIDCAP was developed and validated in two Spanish level III neonatal intensive care units. The questionnaire was answered by 305 health professionals (response rate of 85%). RESULTS The requirements identified in the questionnaire were considered by most respondents as necessary to implementing the NIDCAP, especially more time, education, and staff. Nurses, compared to doctors, thought that more staff was necessary (93% vs. 74%; p < .01). The main obstacle identified in the survey was lack of coordination among different professionals (77%), followed by noise level in the unit (35%). Doctors, in comparison to nurses, considered noise level (61% vs. 23%; p < .01) and nursing staff (56% vs. 29%; p = .05) the most relevant obstacles to NIDCAP implementation. The more experienced professionals perceived their own colleagues as an obstacle, particularly among nursing staff. CONCLUSIONS The implementation of the NIDCAP requires a series of conditions that confirm it is not a trivial process but rather a somewhat laborious one. The lack of coordination among different professionals is often considered the main obstacle.
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Affiliation(s)
- Rocío Mosqueda
- Neonatal Unit, 12 de Octubre Hospital, SAMID Network, Madrid, Spain.
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Alleman BW, Bell EF, Li L, Dagle JM, Smith PB, Ambalavanan N, Laughon MM, Stoll BJ, Goldberg RN, Carlo WA, Murray JC, Cotten CM, Shankaran S, Walsh MC, Laptook AR, Ellsbury DL, Hale EC, Newman NS, Wallace DD, Das A, Higgins RD. Individual and center-level factors affecting mortality among extremely low birth weight infants. Pediatrics 2013; 132:e175-84. [PMID: 23753096 PMCID: PMC3691533 DOI: 10.1542/peds.2012-3707] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine factors affecting center differences in mortality for extremely low birth weight (ELBW) infants. METHODS We analyzed data for 5418 ELBW infants born at 16 Neonatal Research Network centers during 2006-2009. The primary outcomes of early mortality (≤12 hours after birth) and in-hospital mortality were assessed by using multilevel hierarchical models. Models were developed to investigate associations of center rates of selected interventions with mortality while adjusting for patient-level risk factors. These analyses were performed for all gestational ages (GAs) and separately for GAs <25 weeks and ≥25 weeks. RESULTS Early and in-hospital mortality rates among centers were 5% to 36% and 11% to 53% for all GAs, 13% to 73% and 28% to 90% for GAs <25 weeks, and 1% to 11% and 7% to 26% for GAs ≥25 weeks, respectively. Center intervention rates significantly predicted both early and in-hospital mortality for infants <25 weeks. For infants ≥25 weeks, intervention rates did not predict mortality. The variance in mortality among centers was significant for all GAs and outcomes. Center use of interventions and patient risk factors explained some but not all of the center variation in mortality rates. CONCLUSIONS Center intervention rates explain a portion of the center variation in mortality, especially for infants born at <25 weeks' GA. This finding suggests that deaths may be prevented by standardizing care for very early GA infants. However, differences in patient characteristics and center intervention rates do not account for all of the observed variability in mortality; and for infants with GA ≥25 weeks these differences account for only a small part of the variation in mortality.
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Affiliation(s)
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Lei Li
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
| | - John M. Dagle
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Brown University, Providence, Rhode Island
| | - Dan L. Ellsbury
- Center for Research, Education, and Quality, Pediatrix Medical Group, Sunrise, Florida
| | - Ellen C. Hale
- Department of Pediatrics, Emory University School of Medicine, and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Nancy S. Newman
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Dennis D. Wallace
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, North Carolina
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Rockville, Maryland; and
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Profit J, Gould JB, Draper D, Zupancic JAF, Kowalkowski MA, Woodard L, Pietz K, Petersen LA. Variations in definitions of mortality have little influence on neonatal intensive care unit performance ratings. J Pediatr 2013; 162:50-5.e2. [PMID: 22854328 PMCID: PMC3782108 DOI: 10.1016/j.jpeds.2012.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 03/27/2012] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state. STUDY DESIGN We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between. RESULTS There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier. CONCLUSION The time frame used to ascertain mortality had little effect on comparative NICU performance.
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Affiliation(s)
- Jochen Profit
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Jeffrey B Gould
- California Perinatal Quality Care Collaborative, Palo Alto, CA, USA,Division of Neonatology, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University, Palo Alto, CA, USA
| | - David Draper
- Department of Applied Mathematics and Statistics, Baskin School of Engineering, University of California, Santa Cruz, CA, USA
| | - John A F Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA,Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA
| | - Marc A Kowalkowski
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA,Houston Veterans Affairs (VA) Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center; Houston, TX, USA
| | - LeChauncy Woodard
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA,Houston Veterans Affairs (VA) Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center; Houston, TX, USA
| | - Kenneth Pietz
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA,Houston Veterans Affairs (VA) Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center; Houston, TX, USA
| | - Laura A Petersen
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA,Houston Veterans Affairs (VA) Health Services Research and Development Center of Excellence, Health Policy and Quality Program, Michael E. DeBakey VA Medical Center; Houston, TX, USA
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Kutschmann M, Bungard S, Kötting J, Trümner A, Fusch C, Veit C. The care of preterm infants with birth weight below 1250 g: risk-adjusted quality benchmarking as part of validating a caseload-based management system. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:519-26. [PMID: 23049647 DOI: 10.3238/arztebl.2012.0519] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 04/27/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND In Germany, controversy currently surrounds the contention that the quality of care for preterm infants weighing less than 1250 g is best assured by requiring that centers treat a minimum of 30 such cases per year. METHODS A risk-adjusted model was developed on the basis of neonatal data from 7405 preterm infants treated in German centers, and the effect of caseload on risk-adjusted mortality was analyzed. In addition, the discriminative ability of the minimal caseload requirement for quality assessment was studied. The authors designate the quality of care in a particular center as above average if the observed mortality is lower than would have been expected from the risk profile of the preterm infants treated there. RESULTS Risk-adjusted mortality was found to be significantly higher in smaller centers (those with fewer than 30 cases per year) than in larger ones (odds ratio, 1.34). Even among centers whose caseload exceeded the minimum requirement, there was still marked variability in risk-adjusted mortality (range: 3.5% to 28.6%). Of all the preterm infants treated in larger centers, 56% were treated in centers with above-average quality of care. 44% of the centers with above-average quality of care had caseloads in the range of 14 to 29 cases per year. CONCLUSION Because of the marked variability in risk-adjusted mortality, even among larger centers, a caseload of 30 or more cases per year is not a suitable indicator of the quality of care. The neonatal data of external quality assurance should be used to develop an instrument for quality-based coordination of care that takes not just morbidity and mortality, but also the treating centers' competence profiles into account.
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Affiliation(s)
- Marcus Kutschmann
- BQS Institut für Qualität & Patientensicherheit, Düsseldorf, Germany.
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Corchia C, Orlando SM. Level of activity of neonatal intensive care units and mortality among very preterm infants: a nationwide study in Italy. J Matern Fetal Neonatal Med 2012; 25:2739-45. [PMID: 22708555 DOI: 10.3109/14767058.2012.703721] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To investigate the relationships between mortality of infants <32 weeks gestation and neonatal intensive care units' (NICUs) volume of activity, daily number of high-dependent infants (HDIs) and geographical area in Italy. METHODS The study involved 105 neonatal units in 2005. Data were collected prospectically and through monthly cross-sectional investigations. Patients receiving respiratory care were defined as HDIs. Univariate and multivariable methods were used for analysis. RESULTS Babies enrolled were 4014. The overall mortality was 18.8%. An adjusted nearly two-fold increase in mortality was found in Southern compared to Northern regions. Volume of activity was not associated with mortality. When compared to infants admitted to NICUs in the highest tertile of the median number of HDIs/day (>2.5 patients/day), the adjusted odds ratios were 1.52 (95% CI = 1.14-2.02) for those in the 2nd tertile (1.1-2.5 patients/day) and 1.47 (95% CI = 1.02-2.13) for those in the lowest tertile (≤1 patient/day). After stratification by geographical area, this relationship was present in Southern, to a lesser extent in Central, but not in Northern regions. CONCLUSIONS In Italy, striking geographical differences in mortality of very preterm infants are present. NICUs' average daily number of HDIs is a better predictor of mortality than the volume of activity.
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Affiliation(s)
- Carlo Corchia
- International Centre on Birth Defects and Prematurity, Rome, Italy.
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Oral feeding competences of healthy preterm infants: a review. Int J Pediatr 2012; 2012:896257. [PMID: 22675368 PMCID: PMC3362836 DOI: 10.1155/2012/896257] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/17/2012] [Indexed: 11/17/2022] Open
Abstract
Background. With increasing sophistication and technology, survival rates hugely improved among preterm infants admitted to the neonatal intensive care unit. Nutrition and feeding remain a challenge and preterm infants are at high risk of encountering oral feeding difficulties. Objective. To determine what facts may impact on oral feeding readiness and competence and which kind of interventions should enhance oral feeding performance in preterm infants. Search Strategy. MEDILINE database was explored and articles relevant to this topic were collected starting
from 2009 up to 2011. Main Results. Increasingly robust alertness prior to and during feeding does positively impact the infant's feeding Skills. The review found that oral and non-oral sensorimotor interventions, provided singly or in combination, shortened the transition time to independent oral feeding in preterm infants and that preterm infants who received a combined oral and sensorimotor intervention demonstrated more advanced nutritive sucking, suck-swallow and swallow-respiration coordination than those who received an oral or sensorimotor intervention singly.
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Ellsbury DL, Ursprung R. A quality improvement approach to optimizing medication use in the neonatal intensive care unit. Clin Perinatol 2012; 39:1-10. [PMID: 22341532 DOI: 10.1016/j.clp.2011.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite many years of heavy use in premature and critically ill newborns, surprisingly few medications have been rigorously tested in neonatal multicenter randomized clinical trials. Little is known about the pharmacology of these drugs at various birth weights, gestational ages, and chronologic ages. This article describes a quality improvement approach to evaluating and improving neonatal intensive care unit (NICU) medication use, with an emphasis on adaptation of drug use to the specific clinical NICU context and use of system-based changes to minimize harm and maximize clinical benefit.
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Affiliation(s)
- Dan L Ellsbury
- Clinical Quality Improvement MEDNAX Services/Pediatrix Medical Group/American Anesthesiology, 1301 Concord Terrace, Sunrise, FL 33323, USA.
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Thurin SM, Mohsini K, Cho R, Ruediger J. Impact of Nurse-Regulated Feedings on Growth Velocity and Weight Gain of 1200-1500 g Preterm Infants. J Clin Neonatol 2012; 1:21-4. [PMID: 24027680 PMCID: PMC3761988 DOI: 10.4103/2249-4847.92243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose: To evaluate the impact of nurse-regulated feedings (NRFs) on growth velocity and weight gain of 1200–1500 g preterm infants. Subjects: Cohort 1: All preterm infants 1200–1500 g between 1997 and 2001 not on NRF protocol; Cohort 2: All preterm infants 1200–1500 g between 2003 and 2006 on NRF protocol. Both cohorts screened out for small gestation age, major congenital anomalies, intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), culture positive infection at birth, meningitis, and those requiring surgery. Materials and Methods: A before and after matched cohort study was conducted in the years 1997–2001 and 2003–2006, enrolling infants from Covenants Neonatal Intensive Care unit (Level III) using these studies screening protocol. Data on first 62 enrolling infants from both cohorts were used for this study. Both cohorts were matched using gestational age, birth weight, length of stay, initial length. A modified data tool collection set was used for collecting and analyzing nutritional data, this included intake (cal/kg/d, cc/kg/d, and total intake in cc) and route (initial parenteral feedings, mixed parenteral and enteral feedings, full enteral feedings), NRF, and non-NRF (NNRF). Data collection continued until discharge, initiation of adlib feeding, or greater than 50% of nutrition from breast. Discussion: Of the entire population sampled from 1997 to 2006, there were only 59 for NRF and 58 for NNRF. The mean growth velocity (g/kg/d) to reach full enteral feedings for both cohorts was insignificant (t=0.233; P=0.816). This suggested both groups were well matched up to the point of NRF institution for the 2003–2006 cohort years. Results: NRF had a 71% greater growth velocity than NNRF (P<0.001, t=6.618) at the time of discharge, initiation of adlib feeding, or greater than 50% of nutrition from breast. Conclusions: This study demonstrated that the NRF protocol offers a significant advantage in nutritional support than previous feeding regimens in this institution.
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Affiliation(s)
- Serge M Thurin
- Department of Pediatrics, Pediatrix Medical Group, Covenant Healthcare, Michigan State University, Assistant Instructor 1447 North Harrison Street, Michigan, USA
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Garrido MM, Allison KC, Bergeron MJ, Dowd B. Hospital religious affiliation and outcomes for high-risk infants. Med Care Res Rev 2011; 69:316-38. [PMID: 22203647 DOI: 10.1177/1077558711432156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The effect of hospital organizational affiliation on perinatal outcomes is unknown. Using the 2004 American Hospital Association Annual Survey and Healthcare Cost and Utilization Project State Inpatient Databases, the authors examined relationships among organizational affiliation, equipment and service availability and provision, and in-hospital mortality for 5,133 infants across five states born with very low and extremely low birth weight and congenital anomalies. In adjusted bivariate probit selection models, the authors found that government hospitals had significantly higher mortality rates than not-for-profit nonreligious hospitals. Mortality differences among other types of affiliation (Catholic, not-for-profit religious, not-for-profit nonreligious, and for-profit) were not statistically significant. This is encouraging as health care reform efforts call for providers at facilities with different institutional values to coordinate care across facilities. Although there are anecdotes of facility religious affiliation being related to health care decisions, the authors did not find evidence of these relationships in their data.
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Profit J, Gould JB, Zupancic JAF, Stark AR, Wall KM, Kowalkowski MA, Mei M, Pietz K, Thomas EJ, Petersen LA. Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR. J Perinatol 2011; 31:702-10. [PMID: 21350429 PMCID: PMC3205234 DOI: 10.1038/jp.2011.12] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 01/07/2011] [Accepted: 01/18/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality. STUDY DESIGN Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method. RESULT Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%). CONCLUSION A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.
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Affiliation(s)
- J Profit
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
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Survival rates in extremely low birthweight infants depend on the denominator: avoiding potential for bias by specifying denominators. Am J Obstet Gynecol 2011; 205:329.e1-7. [PMID: 21741613 DOI: 10.1016/j.ajog.2011.05.032] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 04/20/2011] [Accepted: 05/12/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of the study was to assess whether recent data reporting survival of preterm infants introduce a bias from the use of varying denominators. STUDY DESIGN We performed a systematic review of hospital survival of infants less than 1000 g or less than 28 weeks. Included publications specified the denominator used to calculate survival rates. RESULTS Of 111 eligible publications only 51 (46%) specified the denominators used to calculate survival rates: 6 used all births, 25 used live births, and 20 used neonatal intensive care unit admissions. Overall rates of survival to hospital discharge ranged widely: from 26.5% to 87.8%. Mean survival varied significantly by denominator: 45.0% (±11.6) using a denominator of all births, 60.7% (±13.2) using live births, or 71.6% (±12.1) using used neonatal intensive care unit admissions (P ≤ .009 or less for each of 3 comparisons). CONCLUSION Variations in reported rates of survival to discharge for extremely low-birthweight (<1000 g) and extremely low-gestational-age (<28 weeks) infants reflect in part a denominator bias that dramatically affects reported data.
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DeMauro SB, Roberts RS, Davis P, Alvaro R, Bairam A, Schmidt B. Impact of delivery room resuscitation on outcomes up to 18 months in very low birth weight infants. J Pediatr 2011; 159:546-50.e1. [PMID: 21592510 DOI: 10.1016/j.jpeds.2011.03.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 03/10/2011] [Accepted: 03/18/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine the relationships between intensity of delivery room resuscitation and short- and long-term outcomes of very low birth weight infants enrolled in the Caffeine for Apnea of Prematurity (CAP) Trial. STUDY DESIGN The CAP Trial enrolled 2006 infants with birthweights between 500 and 1250 g who were eligible for caffeine therapy. All levels of delivery room resuscitation were recorded in study participants. We divided infants in 4 groups of increasing intensity of resuscitation: minimal, n = 343; bag-mask ventilation, n = 372; endotracheal intubation, n = 1205; and cardiopulmonary resuscitation (chest compressions/epinephrine), n = 86. We used multivariable logistic regression models to compare outcomes across the 4 groups. RESULTS The observed rates of death or disability, death, cerebral palsy, cognitive deficit, and hearing loss at 18 months increased with higher levels of resuscitation. Risk of bronchopulmonary dysplasia, severe retinopathy of prematurity, and brain injury also increased with higher levels of resuscitation. Adjustment for prognostic variables reduced the differences between the groups for most outcomes. Only the adjusted rates of bronchopulmonary dysplasia and severe retinopathy remained significantly higher after more intense resuscitation. CONCLUSIONS In CAP Trial participants, the risk of death or neurodevelopmental disability at 18 months did not increase substantially with increasing intensity of delivery room resuscitation.
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Affiliation(s)
- Sara B DeMauro
- Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA 19104, USA
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Medlock S, Ravelli ACJ, Tamminga P, Mol BWM, Abu-Hanna A. Prediction of mortality in very premature infants: a systematic review of prediction models. PLoS One 2011; 6:e23441. [PMID: 21931598 PMCID: PMC3169543 DOI: 10.1371/journal.pone.0023441] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 07/18/2011] [Indexed: 11/25/2022] Open
Abstract
Context Being born very preterm is associated with elevated risk for neonatal mortality. The aim of this review is to give an overview of prediction models for mortality in very premature infants, assess their quality, identify important predictor variables, and provide recommendations for development of future models. Methods Studies were included which reported the predictive performance of a model for mortality in a very preterm or very low birth weight population, and classified as development, validation, or impact studies. For each development study, we recorded the population, variables, aim, predictive performance of the model, and the number of times each model had been validated. Reporting quality criteria and minimum methodological criteria were established and assessed for development studies. Results We identified 41 development studies and 18 validation studies. In addition to gestational age and birth weight, eight variables frequently predicted survival: being of average size for gestational age, female gender, non-white ethnicity, absence of serious congenital malformations, use of antenatal steroids, higher 5-minute Apgar score, normal temperature on admission, and better respiratory status. Twelve studies met our methodological criteria, three of which have been externally validated. Low reporting scores were seen in reporting of performance measures, internal and external validation, and handling of missing data. Conclusions Multivariate models can predict mortality better than birth weight or gestational age alone in very preterm infants. There are validated prediction models for classification and case-mix adjustment. Additional research is needed in validation and impact studies of existing models, and in prediction of mortality in the clinically important subgroup of infants where age and weight alone give only an equivocal prognosis.
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Affiliation(s)
- Stephanie Medlock
- Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Regionalization of health care is a method of providing high-quality, cost-efficient health care to the largest number of patients. Within pediatric medicine, regionalization has been undertaken in 2 areas: neonatal intensive care and pediatric trauma care. The supporting literature for the regionalization of these areas demonstrates the range of studies within this field: studies of neonatal intensive care primarily compare different levels of hospitals, whereas studies of pediatric trauma care primarily compare the impact of institutionalizing a trauma system in a single geographic region. However, neither specialty has been completely regionalized, possibly because of methodologic deficiencies in the evidence base. Research with improved study designs, controlling for differences in illness severity between different hospitals; a systems approach to regionalization studies; and measurement of parental preferences will improve the understanding of the advantages and disadvantages of regionalizing pediatric medicine and will ultimately optimize the outcomes of children.
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Affiliation(s)
- Scott A Lorch
- Department of Pediatrics and Center for Outcomes Research, Children's Hospital of Philadelphia, 3535 Market St, Suite 1029, Philadelphia, PA 19104, USA.
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Mercier CE, Dunn MS, Ferrelli KR, Howard DB, Soll RF. Neurodevelopmental outcome of extremely low birth weight infants from the Vermont Oxford network: 1998-2003. Neonatology 2010; 97:329-38. [PMID: 19940516 PMCID: PMC2889257 DOI: 10.1159/000260136] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Accepted: 07/20/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Physicians and parents face significant uncertainties when making care decisions for extremely low birth weight (ELBW) infants. Many published estimates of death and developmental outcome are from well-funded university programs and may not reflect outcomes of infants from a variety of settings. The best estimates of the probabilities of death and severe disability combine local experience and published data. OBJECTIVE To describe the neurodevelopmental outcome of ELBW infants from centers of the ELBW Infant Follow-Up Group of the Vermont Oxford Network (VON) and to identify characteristics associated with severe disability. METHODS Predefined measures of living situation, health and developmental outcome were collected at 18-24 months' corrected age for infants born from July 1, 1998 to December 31, 2003 with birth weights of 401-1,000 g at 33 North American VON centers. Logistic regression was used to identify characteristics associated with severe disability. RESULTS 6,198 ELBW infants were born and survived until hospital discharge; by the time of follow-up, 88 infants (1.4%) had died. Of the remaining 6,110 infants, 3,567 (58.4%) were evaluated. Severe disability occurred in 34% of the assessed infants. Multivariate logistic regression suggested cystic periventricular leukomalacia, congenital malformation and severe intraventricular hemorrhage were the characteristics most highly associated with severe disability. There were marked variations among the follow-up clinics in the attrition rate. CONCLUSION ELBW infants completing evaluation were at a high risk for severe disability. There are considerable differences among participating centers in attrition at follow-up. Further resources will be needed to study the effect of follow-up care for this group of infants.
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Abstract
Neonatal-Perinatal Medicine has had both its triumphs and its disasters regarding the dissemination of new interventions. Evidence-based medicine (EBM), the integration of clinical expertise, patient values, and best evidence for decision making in patient care, provides a blueprint for how to safely and effectively continue make headway in our rapidly changing field. The principles of EBM have been discussed in multiple articles and primers. EBM involves formulating the appropriate question, finding the evidence, appraising the evidence, and evaluating the clinician's performance in implementing these practices. At an institutional level, this type of thorough evidence review is critical to successful quality improvement projects, particularly if these projects hope to improve clinical outcome. On evaluation of best practice, one sees great variation in the implementation of practices that are strongly evidence based (increased use of antenatal steroids, decreased use of postnatal steroids), practices rich in evidence lacking certainty regarding the best approach (prophylactic indomethacin to prevent intraventricular hemorrhage), and widespread dissemination of practices that have little evidence to support their use (stabilization on high-frequency ventilation).
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Abstract
The Vermont Oxford Network is a not-for-profit organization established in the late 1980s with the goals of improving the quality and safety of medical care for newborn infants and their families through a coordinated program of research, education, and quality improvement. In this paper the authors discuss the activities and programs sponsored by the Network to achieve those goals.
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Affiliation(s)
- Jeffrey D Horbar
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, VT, USA.
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Hall-Barrow J, Hall RW, Burke BL. Telemedicine and neonatal regionalization of care - ensuring that the right baby gets to the right nursery. Pediatr Ann 2009; 38:557-61. [PMID: 19968193 DOI: 10.3928/00904481-20090918-02] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Julie Hall-Barrow
- College of Public Health, University of Arkansas for Medical Science, Center for Distance Health, Little Rock, USA.
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Abstract
This article provides a survey on the concepts, methods, and applications of the study of unwarranted variation in health care with particular attention to children's medical services.
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Affiliation(s)
- David C. Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Parkway, Suite 202, Lebanon, NH 03766, USA,The Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA,Dartmouth Medical School, Hanover, NH, USA
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Gezginç K, Acar A, Peru H, Karataylı R, Çelik Ç, Çapar M. HOW TO MANAGE INTRAUTERINE GROWTH RESTRICTION ASSOCIATED WITH SEVERE PREECLAMPSIA AT 28-34 WEEKS OF GESTATION? ELECTRONIC JOURNAL OF GENERAL MEDICINE 2008. [DOI: 10.29333/ejgm/82609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Outcome of very low birthweight infants after introducing a new standard regime with the early use of nasal CPAP. Eur J Pediatr 2008; 167:909-16. [PMID: 18172681 DOI: 10.1007/s00431-007-0646-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 11/22/2007] [Indexed: 10/22/2022]
Abstract
In this paper, a retrospective study was performed to find out whether the introduction of early nasal continuous positive airway pressure (nCPAP) as a new standard regime of very low birthweight infants will lead to a decreasing tracheal intubation and ventilation rate, as well as to a lower incidence of bronchopulmonary dysplasia in a tertiary-level perinatal centre. Ninety-three infants (study group) with early nCPAP as the first respiratory support were compared to 63 infants (historical control group) born before the use of early nCPAP. No statistically significant differences were found in the baseline characteristics. The main results of the study include reduced intubation mainly in infants with a birthweight <1,000 g (study group): 58% vs. 81% (p < 0.05). The mean duration of ventilation was 248 h (control group) vs. 128 h (study group) (p < 0.001) and 437 h vs. 198 h in infants <1,000 g (p < 0.001). There was significantly reduced incidence of bronchopulmonary dysplasia from 55% to 18% for all surviving infants (p < 0.001), and for infants <1,000 g, it was 90% vs. 30% (p < 0.001). No significant differences for other outcome criteria were noted, but a significant reduction in the use of central i.v. lines, fluids, drugs, volume expansion, sedation, catecholamines, surfactant, steroids and buffer, as well as antibiotics, was observed (p < 0.05). Therefore, we can conclude that early nCPAP is an easy-to-use and safe procedure for very low birthweight infants to treat respiratory distress.
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Chang JJ, Stamilio DM, Macones GA. Effect of hospital volume on maternal outcomes in women with prior cesarean delivery undergoing trial of labor. Am J Epidemiol 2008; 167:711-8. [PMID: 18192674 PMCID: PMC3483027 DOI: 10.1093/aje/kwm363] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The authors examined the association between hospital volume of vaginal birth after cesarean section (VBAC) and VBAC failure, uterine rupture, and maternal morbidity. This was a secondary analysis of data from a retrospective cohort study carried out from 1995 to 2000. Trained nurses extracted detailed information from the medical records of more than 25,000 women with a prior cesarean delivery from 17 community and tertiary-care hospitals in the northeastern United States. The study sample included 12,844 women with prior cesarean section who attempted vaginal delivery with a singleton birth. Annual hospital VBAC volume was divided into tertiles. Primary outcomes included VBAC failure, uterine rupture, and a composite measure of maternal morbidity. The authors used multivariable logistic regression to assess the association between hospital VBAC volume and adverse VBAC outcomes after controlling for confounders. The authors did not find evidence of an association between hospital VBAC volume and the likelihood of adverse outcomes in VBAC after adjustment for patient mix. Other risk factors consistent with prior research were identified, including induction of labor, >/=2 prior cesarean deliveries, preeclampsia, diabetes mellitus, and high birth weight. Prior vaginal delivery was protective against adverse VBAC outcomes. The risk of an adverse VBAC outcome in low-volume hospitals was comparable to that in high-volume hospitals.
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Affiliation(s)
- Jen Jen Chang
- Division of Epidemiology, Department of Community Health, School of Public Health, Saint Louis University, St. Louis, MO 63104, USA
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