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Hospital variation in extremely preterm birth. J Perinatol 2022; 42:1686-1694. [PMID: 36104499 DOI: 10.1038/s41372-022-01505-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 08/19/2022] [Accepted: 08/30/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Given that regionalization of extremely preterm births (EPTBs) is associated with improved infant outcomes, we assessed between-hospital variation in EPTB stratified by hospital level of neonatal care, and determined the proportion of variance explained by differences in maternal and hospital factors. STUDY DESIGN We assessed 7,046,253 births in California from 1997 to 2011, using hospital discharge, birth, and death certificate data. We estimated the association between maternal and hospital factors and EPTB using multivariable regression, calculated hospital-specific EPTB frequencies, and estimated between-hospital variances and median odds ratios, stratified by hospital level of care. RESULT Hospital frequencies of EPTB ranged from 0% to 2.5%. Between-hospital EPTB frequencies varied substantially, despite stratifying by hospital level of care and accounting for confounding factors. CONCLUSION Our results demonstrate differences in EPTBs among hospitals with level 1 and 2 neonatal care, an area to target for future research and quality improvement.
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Qu W, Shen Y, Qi Y, Jiang M, Zheng X, Zhang J, Wu D, He W, Geng W, Hei M. Comparison of four neonatal transport scoring methods in the prediction of mortality risk in full-term, out-born infants: a single-center retrospective cohort study. Eur J Pediatr 2022; 181:3005-3011. [PMID: 35616731 DOI: 10.1007/s00431-022-04506-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED Neonatal transport scoring systems can assess severity before and after transport, improve transport efficiency, and predict the occurrence of critical illness. The aim of this study was to compare four neonatal transport scoring methods to predict mortality risk and clinical utility within the first week after transportation. This was a single-center retrospective cohort study. All patients were full-term, out-born neonates. Each patient was assessed by the Transport Risk Index of Physiologic Stability (TRIPS), Mortality Index for Neonatal Transportation (MINT), Transport-Related Mortality Score (TREMS), and Neonatal Critical Illness Score (NCIS) scoring methods. Receiver operating characteristic (ROC) curves and decision curve analysis (DCA) for each method were compared for their utility in predicting mortality risk within the 1st week after admission. In total, 368 full-term infants were included (368/770, 47.8% of all transported infants). Within the 1st week after admission, five infants (1.36%, 5/368) died while receiving advanced life support and full treatment, and 24 infants (6.52%, 24/368) died soon after they were discharged against medical advice. The areas under the curve (AUCs) for the MINT, TRIPS, TREMS, and NCIS for the prediction of mortality were 0.822, 0.827, 0.643, and 0.731, respectively (all p < 0.05). However, the clinical net benefits for the MINT and TRIPS were far superior than those for the NCIS and TREMS. CONCLUSION It was concluded that the TRIPS and MINT might be more suitable for the prediction of mortality in full-term, out-born neonates in the neonatal intensive care unit (NICU) within the 1st week after transportation. WHAT IS KNOWN • Neonatal transport scores can assess not only the mortality risk during transportation but also the mortality risk of critically ill newborns after admission to the NICU. • The effectiveness of neonatal transport scores in predicting mortality risk is different. WHAT IS NEW • Our data indicate that the diagnostic efficacy of the MINT, TRIPS, and NCIS in the prediction of full-term infant mortality was high. • The TRIPS and MINT scores had better clinical utility and could be used to predict mortality within the 1st week after transportation in full-term out-born neonates.
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Affiliation(s)
- Wenwen Qu
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,General Respiratory Department of Beijing Jingdu Children's Hospital, Beijing, China
| | - Yanhua Shen
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Yujie Qi
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Min Jiang
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Xu Zheng
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Jinjing Zhang
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Dan Wu
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Wenwen He
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Wenjing Geng
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,National Center for Children's Health, Beijing, China
| | - Mingyan Hei
- Neonatal Center, Beijing Children's Hospital, Capital Medical University, Beijing, China. .,National Center for Children's Health, Beijing, China. .,Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China.
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Abstract
IMPORTANCE Birth at hospitals with an appropriate level of neonatal intensive care units is associated with better neonatal outcomes. The primary sources for information about hospital neonatal unit levels for prospective parents, referring physicians, and the public are hospital websites, but the accuracy of neonatal unit capacity is unclear. OBJECTIVE To determine if hospital websites accurately report the capabilities of intermediate (ie, level II) units, which are intended for care of newborns with low to moderate illness levels or the stabilization of newborns prior to transfer. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study compared descriptions of level II unit capabilities on hospital web pages in 10 large states with their respective state-level designation. Analyzed units were located in the 10 states with the highest number of live births in 2019 (excluding states with no level II regulations) and had active websites as of May 2021. MAIN OUTCOMES AND MEASURES Hospital websites were assessed for whether there was any mention of the unit, the description of the unit was provided, the unit was identified as a level III or both levels II and III, the terms "neonatal intensive care unit" or "NICU" were used without indicating limits in care available or newborn acuity, or the unit was claimed to provide the most advanced level of care. RESULTS A total 28 states had no regulation of nursery unit levels; in the 10 large, regulated states, web descriptions of level II units were incomplete for 39.2% of hospitals (95% CI, 33.3%-45.3%) and inaccurate for 24.6% (95% CI, 19.6%-30.2%). Within incomplete descriptions, 2.6% (95% CI, 1.1%-5.3%) of hospitals did not mention an advanced care unit and 22.0% (95% CI, 17.2%-27.5%) identified a level II unit without providing further description. Within inaccurate descriptions, 25.4% (95% CI, 20.3%-31.0%) of hospitals described the unit as a "neonatal intensive care unit" or "NICU" without any qualification and 9.3% (95% CI, 6.3%-13.5%) claimed that the unit provided the most advanced neonatal care or care to the sickest newborns; 3.0% of hospitals (95% CI, 1.3%-6.0%) stated that their unit was level III and 1.5% (95% CI, 0.4%-3.8%) as level II and III. Across states there was substantial variation in rates of incompleteness and inaccuracy. CONCLUSIONS AND RELEVANCE Incomplete and inaccurate hospital web descriptions of intermediate newborn care units are common. These deficits can mislead parents, clinicians, and the public about the appropriateness of a hospital for sick newborns, which raises important ethical questions.
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Affiliation(s)
- David C. Goodman
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Children’s Hospital at Dartmouth, Lebanon, New Hampshire
| | - Timothy J. Price
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - David Braun
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Pediatrics, Kaiser Permanente Southern California, Panorama City
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Desplanches T, Morgan AS, Jones P, Diguisto C, Zeitlin J, Martin-Marchand L, Benhammou V, Lecomte B, Rozé JC, Truffert P, Ancel PY, Sagot P, Roussot A, Fresson J, Blondel B. Risk factors for very preterm delivery out of a level III maternity unit: The EPIPAGE-2 cohort study. Paediatr Perinat Epidemiol 2021; 35:694-705. [PMID: 33956996 DOI: 10.1111/ppe.12770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6 weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance. CONCLUSIONS Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.
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Affiliation(s)
- Thomas Desplanches
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Andrei S Morgan
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Neonatology, Elizabeth Garrett Anderson Institute for Women's Health, UCL, London, UK.,Embrace Yorkshire and Humber Infant and Paediatric Transport Service, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Peter Jones
- SAMU de Paris, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,Réanimation Pédiatrique AP-HP, Hôpital Robert Debré, Paris, France
| | - Caroline Diguisto
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Obstetrics and Gynecology, University Hospital of Tours, Tours University, Tours, France
| | - Jennifer Zeitlin
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Laetitia Martin-Marchand
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | - Valérie Benhammou
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
| | | | - Jean-Christophe Rozé
- Pediatric Intensive Care Unit, Mothers' and Children's Hospital, Nantes Teaching Hospital, Nantes, France
| | - Patrick Truffert
- Neonatal Intensive Care Unit, Jeanne de Flandre Hospital, CHRU Lille, Lille, France
| | - Pierre-Yves Ancel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Clinical Research Unit, Center for Clinical Investigation P1419, CHU Cochin Broca Hôtel-Dieu, Paris, France
| | - Paul Sagot
- CHRU Dijon, Department of Gynaecology, Obstetrics, Foetal Medicine and Infertility, Dijon, France
| | - Adrien Roussot
- Biostatistics and Bioinformatics (DIM), University Hospital, Dijon, France.,Bourgogne Franche-Comté University, Dijon, France
| | - Jeanne Fresson
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France.,Department of Medical Information, University Hospital (CHRU) Nancy, Nancy, France
| | - Béatrice Blondel
- Obstetrical, Perinatal, and Pediatric Epidemiology Team, Center of Research in Epidemiology and Statistics (U1153), Université de Paris, INSERM, Paris, France
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Nourkami-Tutdibi N, Tutdibi E, Faas T, Wagenpfeil G, Draper ES, Johnson S, Cuttini M, Rafei RE, Seppänen AV, Mazela J, Maier RF, Nuytten A, Barros H, Rodrigues C, Zeitlin J, Zemlin M. Neonatal Morbidity and Mortality in Advanced Aged Mothers-Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm. Front Pediatr 2021; 9:747203. [PMID: 34869105 PMCID: PMC8634642 DOI: 10.3389/fped.2021.747203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background: As childbearing is postponed in developed countries, maternal age (MA) has increased over decades with an increasing number of pregnancies between age 35-39 and beyond. The aim of the study was to determine the influence of advanced (AMA) and very advanced maternal age (vAMA) on morbidity and mortality of very preterm (VPT) infants. Methods: This was a population-based cohort study including infants from the "Effective Perinatal Intensive Care in Europe" (EPICE) cohort. The EPICE database contains data of 10329 VPT infants of 8,928 mothers, including stillbirths and terminations of pregnancy. Births occurred in 19 regions in 11 European countries. The study included 7,607 live born infants without severe congenital anomalies. The principal exposure variable was MA at delivery. Infants were divided into three groups [reference 18-34 years, AMA 35-39 years and very(v) AMA ≥40 years]. Infant mortality was defined as in-hospital death before discharge home or into long-term pediatric care. The secondary outcome included a composite of mortality and/or any one of the following major neonatal morbidities: (1) moderate-to-severe bronchopulmonary dysplasia; (2) severe brain injury defined as intraventricular hemorrhage and/or cystic periventricular leukomalacia; (3) severe retinopathy of prematurity; and (4) severe necrotizing enterocolitis. Results: There was no significant difference between MA groups regarding the use of surfactant therapy, postnatal corticosteroids, rate of neonatal sepsis or PDA that needed pharmacological or surgical intervention. Infants of AMA/vAMA mothers required significantly less mechanical ventilation during NICU stay than infants born to non-AMA mothers, but there was no significant difference in length of mechanical ventilation and after stratification by gestational age group. Adverse neonatal outcomes in VPT infants born to AMA/vAMA mothers did not differ from infants born to mothers below the age of 35. Maternal age showed no influence on mortality in live-born VPT infants. Conclusion: Although AMA/vAMA mothers encountered greater pregnancy risk, the mortality and morbidity of VPT infants was independent of maternal age.
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Affiliation(s)
- Nasenien Nourkami-Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Erol Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Theresa Faas
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University Medical Center, Institute of Medical Biometry, Epidemiology and Medical Informatics, Homburg, Germany
| | - Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rym El Rafei
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Anna-Veera Seppänen
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Jan Mazela
- Department of Neonatology and Neonatal Infectious Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Rolf Felix Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | | | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Carina Rodrigues
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Jennifer Zeitlin
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Michael Zemlin
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
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