The regionalization of perinatal care in Wales and Washington State

United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement

OBJECTIVE

Summarize policies that support maternal and neonatal transport among states and territories.

STUDY DESIGN

Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement.

RESULTS

Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies.

CONCLUSION

The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes.

The effectiveness of regionalization of perinatal care services--a systematic review

BACKGROUND

Several reports recommend the implementation of perinatal regionalization for improvements in maternal and neonatal outcomes, while research evidence on the effectiveness of perinatal regionalization has been limited. The interventional studies have been assessed for robust evidence on the effectiveness of perinatal regionalization on improving maternal and neonatal health outcomes.

METHODS

Bibliographic databases of Medline, EMbase, EconLit, HMIC have been searched using sensitive search terms for interventional studies that reported important patient or process outcomes. At least two authors assessed eligibility for inclusion and the risk of biases and extracted data from the included studies. As meta-analysis was not possible, a narrative analysis as well as a 'vote-counting' analysis has been conducted for important outcomes.

RESULTS

After initial screenings 53 full text papers were retrieved. Eight studies were included in the review from the USA, Canada and France. Studies varied in their designs, and in the specifications of the intervention and setting. Only three interrupted time series studies had a low risk of bias, of which only one study reported significant reductions in neonatal and infant mortality. Studies of higher risk of bias were more likely to report improvements in outcomes.

CONCLUSIONS

Implementing perinatal regionalization programs is correlated with improvements in perinatal outcomes, but it is not possible to establish a causal link. Despite several high profile policy statements, evidence of effect is weak. It is necessary to assess the effectiveness of perinatal regionalization using robust research designs in a more diverse range of countries.

Does facility based newborn care improve neonatal outcomes? A review of evidence

CONTEXT

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.

OBJECTIVE

To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.

EVIDENCE ACQUISITION

Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.

RESULTS

A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.

CONCLUSIONS

Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

Severe sepsis in pre-hospital emergency care: analysis of incidence, care, and outcome

RATIONALE

Severe sepsis is common and highly morbid, yet the epidemiology of severe sepsis at the frontier of the health care system-pre-hospital emergency care-is unknown.

OBJECTIVES

We examined the epidemiology of pre-hospital severe sepsis among emergency medical services (EMS) encounters, relative to acute myocardial infarction and stroke.

METHODS

Retrospective study using a community-based cohort of all nonarrest, nontrauma King County EMS encounters from 2000 to 2009 who were transported to a hospital.

MEASUREMENTS AND MAIN RESULTS

Overall incidence rate of hospitalization with severe sepsis among EMS encounters, as well as pre-hospital characteristics, admission diagnosis, and outcomes. Among 407,176 EMS encounters, we identified 13,249 hospitalizations for severe sepsis, of whom 2,596 died in the hospital (19.6%). The crude incidence rate of severe sepsis was 3.3 per 100 EMS encounters, greater than for acute myocardial infarction or stroke (2.3 per 100 and 2.2 per 100 EMS encounters, respectively). More than 40% of all severe sepsis hospitalizations arrived at the emergency department after EMS transport, and 80% of cases were diagnosed on admission. Pre-hospital care intervals, on average, exceeded 45 minutes for those hospitalized with severe sepsis. One-half or fewer of patients with severe sepsis were transported by paramedics (n = 7,114; 54%) or received pre-hospital intravenous access (n = 4,842; 37%).

CONCLUSIONS

EMS personnel care for a substantial and increasing number of patients with severe sepsis, and spend considerable time on scene and during transport. Given the emphasis on rapid diagnosis and intervention for sepsis, the pre-hospital interval may represent an important opportunity for recognition and care of sepsis.

Categorization, designation, and regionalization of emergency care: definitions, a conceptual framework, and future challenges

This article reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.

Organisation of obstetric services for very preterm births in Europe: results from the MOSAIC project

OBJECTIVE

To study the impact of the organisation of obstetric services on the regionalisation of care for very preterm births.

DESIGN

Cohort study.

SETTING

Ten European regions covering 490 000 live births.

POPULATION

All children born in 2003 between 24 and 31 weeks of gestation.

METHOD

The rate of specialised maternity units per 10 000 total births, the proportion of total births in specialised units and the proportion of very preterm births by referral status in specialised units were compared.

MAIN OUTCOME MEASURE

Birth in a specialised maternity unit (level III unit or unit with a large neonatal unit (at least 50 annual very preterm admissions).

RESULTS

The organisation of obstetric care varied in these regions with respect to the supply of level III units (from 2.3 per 10 000 births in the Portuguese region to 0.2 in the Polish region), their characteristics (annual number of deliveries, 24 hour presence of a trained obstetrician) and the proportion of all births (term and preterm) that occur in these units. The proportion of very preterm births in level III units ranged from 93 to 63% in the regions. Different approaches were used to obtain a high level of regionalisation: high proportions of total deliveries in specialised units, high proportions of in utero transfers or high proportions of high-risk women who were referred to a specialised unit during pregnancy.

CONCLUSION

Consensus does not exist on the optimal characteristics of specialised units but regionalisation may be achieved in different models of organisation of obstetric services.

Rural surgery in British Columbia: is there anybody out there?

OBJECTIVE

To document surgical procedures performed in British Columbia between 1996 and 2001 at rural hospital sites with no resident specialist surgeons and to define the scope of practice of general practitioner (GP)-surgeons at these small-volume surgical sites.

METHODS

We obtained data from published information available in the medical directories for British Columbia and from the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) to conduct a retrospective study of all rural BC hospitals with surgical programs that had no resident specialist surgeon and relied on GP-surgeons for emergency surgical care between 1996 and 2001. We studied surgical programs at the 12 hospitals that met inclusion criteria and interviewed the physician or nurse responsible for the program. Outcomes were measured in terms of the types and volumes of surgical procedures (elective and emergency) from 1996 to 2001, including itinerant surgery.

RESULTS

On average, 2690 surgical procedures were performed annually at the 12 hospitals included in the study. Endoscopy, hand surgery, cesarean section, herniorrhaphy, tonsillectomy and dilation and curettage (D&C) were among the top elective and emergency procedures. For each hospital, between 8 and 26 procedures of hand surgery, cesarean section, herniorrhaphy, D&C and appendectomy were performed each year. In the 12 communities studied, 19% of all surgery was emergency and 81% elective. There was significant overlap in the types of emergency and elective procedures. GP-surgeons carried out most of the emergency procedures, which nonetheless accounted for a small portion of their surgical work.

CONCLUSION

GP-surgeons still perform a significant number of emergency and elective surgical procedures in rural BC hospitals. This study defines useful procedures for GP-surgeons in communities without the population base to sustain a resident specialist surgeon. This information can be used to structure training programs for GP-surgeons that will adequately meet the needs of rural communities.

Delivery models of rural surgical services in British Columbia (1996-2005): are general practitioner-surgeons still part of the picture?

OBJECTIVE

To define the models of surgical service delivery in rural communities that rely solely on general practitioner (GP)-surgeons for emergency care, to examine how they have changed over the past decade and to identify some effects on communities that have lost their local surgical program.

METHODS

We undertook a retrospective study using the Population Utilization Rates and Referrals For Easy Comparative Tables database (versions 6.0 and 9.0) and telephone interviews to hospitals that we identified. We included all hospitals in rural British Columbia with surgical programs that had no resident specialist surgeon and that relied on general practitioner-surgeons (GP-surgeons) for emergency surgical care. We examined surgical program characteristics, community size, distance from referral centre, role of itinerant surgery, where GPs were trained, their age and years of experience and referral rates for appendectomies and obstetrics.

RESULTS

Changes over the past decade include a decrease in the total number of GP-surgeons operating in these communities, more itinerant surgery and the loss of 3 of 12 programs. GP-surgeons are older, are usually foreign-trained and have more than 5 years of experience. Communities with no local program or that rely on solo practitioners refer more emergencies out of the community and do less maternity care than those with more than a single GP-surgeon.

CONCLUSION

GP-surgeons still play an integral role in the provision of emergency and elective surgical services in rural communities without the population base to sustain resident specialist surgeons. As GP-surgeons retire and surgical programs close, there is no accredited training program to replace them. More outcome comparisons between procedures performed by GP-surgeons and general surgeons are needed, as is the creation of a nationally accredited training program to replace these practitioners as they retire.

Characteristics of neonatal units that care for very preterm infants in Europe: results from the MOSAIC study

OBJECTIVES

We sought to compare guidelines for level III units in 10 European regions and analyze the characteristics of neonatal units that care for very preterm infants.

METHODS

The MOSAIC (Models of Organising Access to Intensive Care for Very Preterm Births) project combined a prospective cohort study on all births between 22 and 31 completed weeks of gestation in 10 European regions and a survey of neonatal unit characteristics. Units that admitted > or = 5 infants at < 32 weeks of gestation were included in the analysis (N = 111). Place of hospitalization of infants who were admitted to neonatal care was analyzed by using the cohort data (N = 4947). National or regional guidelines for level III units were reviewed.

RESULTS

Six of 9 guidelines for level III units included minimum size criteria, based on number of intensive care beds (6 guidelines), neonatal admissions (2), ventilated patients (1), obstetric intensive care beds (1), and deliveries (2). The characteristics of level III units varied, and many were small or unspecialized by recommended criteria: 36% had fewer than 50 very preterm annual admissions, 22% ventilated fewer than 50 infants annually, and 28% had fewer than 6 intensive care beds. Level II units were less specialized, but some provided mechanical ventilation (57%) or high-frequency ventilation (20%) or had neonatal surgery facilities (17%). Sixty-nine percent of level III and 36% of level I or II units had continuous medical coverage by a qualified pediatrician. Twenty-two percent of infants who were < 28 weeks of gestation were treated in units that admitted fewer than 50 very preterm infants annually (range: 2%-54% across the study regions).

CONCLUSIONS

No consensus exists in Europe about size or other criteria for NICUs. A better understanding of the characteristics associated with high-quality neonatal care is needed, given the high proportion of very preterm infants who are cared for in units that are considered small or less specialized by many recommendations.

Trends in Perinatal Regionalization and the Role of Managed Care

OBJECTIVE

To describe trends in regionalization of perinatal care and identify factors that predict the extent of regionalization.

METHODS

Data were drawn for four states for every year between 1989 and 1998. Panel data models estimated the effect of managed care enrollment on site of delivery for low, very low, and extremely low birth weight neonates.

RESULTS

Strong evidence for regionalization over time was observed for North Carolina and Illinois, with little change in site of delivery in Washington. A shift from level III to level II hospitals was observed for low and very low birth weight neonates in California. Although managed care enrollment increased substantially in all four states, managed care had no effect on site of delivery; that is, the effect of managed care was near zero and not statistically significant in any state.

CONCLUSION

Evidence supports the delivery of high-risk neonates at tertiary care centers. Despite changes in site of delivery, the percentages of very low birth weight neonates delivered at level III hospitals were substantially lower than the goal of 90% set by Healthy People 2010. Financial pressures introduced by managed care cannot be blamed for the failure to meet this goal.

LEVEL OF EVIDENCE

II-2.

Why do patients and families request transfers to tertiary care? a qualitative study

Interhospital transfers comprise a significant and increasing proportion of admissions to tertiary care centers. Patient dissatisfaction with the quality of hospital care may play an important role in these trends. The objective of this study was to describe why and how patients and surrogates request transfers to tertiary care. We interviewed 32 patients transferred to the Johns Hopkins Hospital, a US tertiary care center, or their surrogate decision-makers using a semi-structured, open-ended, iterative protocol. We used ethnographic decision modeling to develop an influence diagram of the decision. We contrasted subjects' perceptions of situations where patients did and did not request transfer to describe the threshold for requesting transfer. Subjects reported three major influences on the request to transfer to tertiary care: the quality of care at the community hospital compared to the tertiary center; the severity and potential consequences of the current illness; and their relationship with community hospitals, physicians, and tertiary care. Subjects' perceptions of the quality differential between community hospitals and tertiary centers focused on communication and medical errors rather than specialized care, hospital volume, or teaching status. Thresholds for when patients requested transfers were influenced by relationships with community hospitals and physicians and previous experience with tertiary care. This model provides a framework for understanding requests to transfer to tertiary care. Further investigation into the elements we have described might provide insights into improvements in the quality of care at community hospitals that might reduce the rates of requests for transfer. Our results also highlight the importance of including patient or surrogate perspectives in evaluations of the appropriateness of care.

European indicators of health care during pregnancy, delivery and the postpartum period

OBJECTIVES

To describe variation across Europe in PERISTAT indicators of health care in the perinatal period, and to assess the comparability of these indicators.

STUDY DESIGN

The PERISTAT feasibility study provides the source for this descriptive study, covering 15 European countries. Comparative analysis includes descriptions of births following management of sub-fertility, timing of first antenatal visit, onset of labour, mode of delivery, place of birth, preterm births in units without NICU, and breast-feeding uptake.

RESULTS

There is broad variation in the availability to provide data on perinatal indicators, and in perinatal health care across the European Union.

CONCLUSIONS

This paper describes the challenge of identifying indicators that are meaningful and robust for the full distribution of health care systems represented in the European Union. Further work is needed to ensure that the implementation of each indicator is comparable across member states.

Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990-1999

BACKGROUND

While agreement exists about the benefits of regionalization for high-risk births, little evidence exists regarding regionalization of low-risk births. The objective of this study was to investigate the impact of regionalization on neonatal survival focussed on low-risk births.

METHODS

Data from the perinatal birth register of Hesse, 1990-1999 were used comprising detailed information about 582,655 births covering more than 95% of all births in Hesse. Outcome events were death during labour or within the first 7 days of life (early-neonatal death). Mortality rates and corresponding 95% CI were calculated according to hospital volume measured by births per year and birthweight categories.

RESULTS

Birthweight-specific mortality rates were lowest in large delivery units and highest in smaller delivery units. This gradient was especially pronounced within low-risk births and was also confirmed in several logistic regression models adjusting for additional risk factors. A more than threefold mortality risk was observed in hospitals with <500 births/year compared with hospitals with >1,500 births/year (odds ratio = 3.48; 95% CI: 2.64-4.58). Further trend analyses indicated that prenatal prevention programmes and the increasing usage of modern prenatal diagnostic procedures have not reduced this gradient in recent years.

CONCLUSIONS

This analysis presents an urgent public policy issue of whether such elevated risk in smaller delivery units is acceptable or if further consolidation of birthing units should be considered to reduce early-neonatal mortality.

Quality of care in the rural context: a proposed research agenda

The quality of health care provided in rural areas is critical to rural patients and providers and will shape the future evolution of the rural health care system. Past research has focused almost exclusively on disease-specific comparisons of the quality of care rendered in rural as compared with urban areas, which ignores the fact that it is the functioning of the entire system of care that determines whether or not rural residents receive high quality care. Future research should focus on the functioning of the entire rural system of care. To accomplish this objective, we suggest investments in the following areas: the creation of a national database that collects information on the process and outcome of care delivered to rural populations, the incorporation of human factors research into our research agenda, greater emphasis on the importance of sociodemographic and cultural issues to the quality of care, and a shift to a focus on populations as opposed to individuals.

Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care

BACKGROUND

Despite high per capita health care expenditure, the United States has crude infant survival rates that are lower than similarly developed nations. Although differences in vital recording and socioeconomic risk have been studied, a systematic, cross-national comparison of perinatal health care systems is lacking.

OBJECTIVE

To characterize systems of reproductive care for the United States, Australia, Canada, and the United Kingdom, including a detailed analysis of neonatal intensive care and mortality.

DESIGN/METHODS

Comparison of selected indicators of reproductive care and mortality from 1993-2000 through a systematic review of journal and government publications and structured interviews of leaders in perinatal and neonatal care.

RESULTS

Compared with the other 3 countries, the United States has more neonatal intensive care resources yet provides proportionately less support for preconception and prenatal care. Unlike the United States, the other countries provided free family planning services and prenatal and perinatal physician care, and the United Kingdom and Australia paid for all contraception. The United States has high neonatal intensive care capacity, with 6.1 neonatologists per 10 000 live births; Australia, 3.7; Canada, 3.3; and the United Kingdom, 2.7. For intensive care beds, the United States has 3.3 per 10 000 live births; Australia and Canada, 2.6; and the United Kingdom, 0.67. Greater neonatal intensive care resources were not consistently associated with lower birth weight-specific mortality. The relative risk (United States as reference) of neonatal mortality for infants <1000 g was 0.84 for Australia, 1.12 for Canada, and 0.99 for the United Kingdom; for 1000 to 2499 g infants, the relative risk was 0.97 for Australia, 1.26 for Canada, and 0.95 for the United Kingdom. As reported elsewhere, low birth weight rates were notably higher in the United States, partially explaining the high crude mortality rates.

CONCLUSIONS

The United States has significantly greater neonatal intensive care resources per capita, compared with 3 other developed countries, without having consistently better birth weight-specific mortality. Despite low birth weight rates that exceed other countries, the United States has proportionately more providers per low birth weight infant, but offers less extensive preconception and prenatal services. This study questions the effectiveness of the current distribution of US reproductive care resources and its emphasis on neonatal intensive care.

Perinatal regionalization and neonatal mortality in North Carolina, 1968-1994

OBJECTIVE

Our purpose was to analyze trends across time in the regionalization of low-birth-weight births and time trends for the association between regionalization and decreased neonatal mortality.

STUDY DESIGN

Data on 69,452 neonates with birth weights of 500 to 2000 g were obtained from electronic files of birth certificates. Hospitals' perinatal services were classified as level 1, 2, or 3 (level 3 refers to tertiary referral centers).

RESULTS

The likelihood of birth outside level 3 hospitals decreased from 1968 to 1994, with an average annual decrease of 24% for infants weighing 500 to 1500 g and 20% for infants weighing 1501 to 2000 g. After 1974, birth in a hospital with level 3 services was associated with a lower risk of dying. The strength of this association increased in the 1990s.

CONCLUSIONS

In North Carolina the proportion of infants weighing <2000 g born outside a hospital with level 3 neonatal services declined from 1974 through 1994. After 1974, birth in a hospital with level 3 neonatal services was associated with lower neonatal mortality.