Care System Redesign for Preterm Children After Discharge From the NICU

Birth Weight and Gestational Age as Modifiers of Rehospitalization after Neonatal Intensive Care Unit Admission

OBJECTIVE

This study aimed to assess interaction effects between gestational age and birth weight on 30-day unplanned hospital readmission following discharge from the neonatal intensive care unit (NICU).

STUDY DESIGN

This is a retrospective study that uses the study site's Children's Hospitals Neonatal Database and electronic health records. Population included patients discharged from a NICU between January 2017 and March 2020. Variables encompassing demographics, gestational age, birth weight, medications, maternal data, and surgical procedures were controlled for. A statistical interaction between gestational age and birth weight was tested for statistical significance.

RESULTS

A total of 2,307 neonates were included, with 7.2% readmitted within 30 days of discharge. Statistical interaction between birth weight and gestational age was statistically significant, indicating that the odds of readmission among low birthweight premature patients increase with increasing gestational age, whereas decrease with increasing gestational age among their normal or high birth weight peers.

CONCLUSION

The effect of gestational age on odds of hospital readmission is dependent on birth weight.

KEY POINTS

· Population included patients discharged from a NICU between January 2017 and March 2020.. · A total of 2,307 neonates were included, with 7.2% readmitted within 30 days of discharge.. · The effect of gestational age on odds of hospital readmission is dependent on birth weight..

Bridging the gap between healthcare sectors: Facilitating the transition from NICU to the municipality and home for families with premature infants

PURPOSE

The transition from hospital to home can be challenging for parents of prematurely born infants. The aim of this ethnographic study was to describe a multidisciplinary and cross-sectoral discharge conference for families with premature infants transitioning from a neonatal intensive care unit to municipal healthcare services.

DESIGN AND METHODS

An ethnographically/anthropologically inspired qualitative design was adopted. We conducted four participant observations of multidisciplinary and cross-sectoral discharge conferences and 12 semistructured interviews with four neonatologists, four nurses, and four health visitors who had attended one of the conferences. Salient themes were generated by two-part analysis consisting of a thematic analysis followed by Turner's ritual analysis.

RESULTS

This study illustrated how multidisciplinary and cross-sectoral discharge conferences improved the quality of care for premature infants and their families in their transition process which was perceived as complex. These conferences contributed to promoting a sense of coherence and continuity of care. The healthcare professionals experienced that this event may be characterized as a ritual, which created structures that promoted cross-sectoral cooperation and communication while increasing interdisciplinary knowledge sharing. Thus, the conferences triggered a sense that the participants were building bridges to unite healthcare sectors, ensuring a holistic and coordinated approach to meet the unique needs of the infants and their families.

IMPLICATIONS FOR PRACTICE

This study presented a unique holistic and family-centered approach to constructing multidisciplinary and cross-sectoral discharge conferences that seemed to underpin the quality of interdisciplinary and health-related knowledge sharing and establish a crucial starting point for early interventions, preventive measures, and health-promoting efforts. Hopefully, our findings will encourage others to rethink the discharge conference as a transitional ritual that may potentially bridge the gap between healthcare sectors. Specifically, our findings contribute to the mounting body of knowledge of family-centered care by showing how healthcare professionals may-in a meaningful and tangible manner-operate, develop, and implement this somewhat elusive theoretical foundation in their clinical practice.

Racial and Ethnic Disparities in the Medical Home for Children Born Premature in the National Survey of Children's Health

OBJECTIVE

Children born premature are more likely to be from minoritized racial and ethnic groups and face chronic health and developmental problems. The medical home aims to comprehensively address health and social needs of all families. This study evaluates racial and ethnic disparities in the prevalence of a medical home among children born premature compared to children born full-term.

METHODS

A 2017-18 National Survey of Children's Health data set was used to calculate the medical home performance measure and subcomponents for children aged 0 to 17 born premature (n = 5633) or full-term (n = 45,819). Chi square and logistic regression assessed magnitude and significance of variations by race and ethnicity and prematurity status.

RESULTS

Prematurity prevalence differed by race and ethnicity (12.0% non-Hispanic Black [NHB], 12.8% Hispanic, 11.1% Multiracial/Other, 11.0% non-Hispanic White [NHW]). Minoritized children born premature had lower adjusted odds of receiving care in a medical home compared to NHW peers (eg, NHB adjusted odds ratio [aOR] 0.54 [95% confidence interval {CI}: 0.38-0.76] and Hispanic aOR 0.56 [95% CI: 0.40-0.79]). Differences were greater in magnitude among children born premature compared to full-term peers (eg, NHB premature aOR 0.54 [95% CI: 0.38-0.76] vs NHB full-term aOR 0.67 [95% CI: 0.58-0.78]), with similar results for "personal doctor/nurse" and "usual sick care."

CONCLUSIONS

Racial and ethnic disparities exist in the medical home among children born premature, some more pronounced than full-term peers. To deliver equitable care for all children, efforts are needed to expand access to and improve the medical home, including reliable routine and sick care and stronger family-provider relationships.

Previous missed visits and independent risk of loss to follow-up in the high-risk neonatal follow-up clinic

BACKGROUND

Neonatal intensive care unit (NICU) patients are at high risk for developmental delays. As a result, many are seen in neonatal follow-up (NFU) clinics. Disparities in NFU follow-up rates by social determinants of health exist.

AIMS

Determine how the number of missed visits (composed of patient-canceled visits and no-show visits) relates to risk of loss to follow-up in the NFU clinic.

STUDY DESIGN

Retrospective cohort study at a regional specialty center in the United States.

SUBJECTS

262 patients born between January 1, 2014, and December 31, 2017, who were referred to the NFU clinic.

OUTCOME MEASURES

Logistic binomial regression was used to model risk ratio of loss to follow-up over two years, defined as not attending a recommended follow-up visit and not informing the clinic of a reason for discontinued care.

RESULTS

Of 262 infants, 220 patients (84 %) were seen for at least one visit and 143 (65 %) completed follow-up. Younger maternal age, maternal smoking during pregnancy, maternal drug use during pregnancy, and public insurance were all associated with missing more visits. For each additional missed visit, the risk of loss to follow-up was 1.73 times higher unadjusted (95 % CI: 1.33, 2.26) and 1.81 times higher (95 % CI: 1.36, 2.40) after adjusting for confounders. The risk ratio of loss to follow-up for no-show visits was three times higher than that for patient-canceled visits.

CONCLUSIONS

Each missed visit was independently associated with higher risk of loss to follow-up from NFU clinic, even after adjusting for other risk factors.

Neonatal Intensive Care Unit to Home Discharge Communication: A Quality Improvement Project

Neonatal intensive care unit (NICU) graduates require complex services after discharge. The NICU discharge process at Children's Hospital at Montefiore-Weiler, Bronx, NY (CHAM-Weiler) lacked a system for routine primary care provider (PCP) notification. Here, we describe a quality improvement project to improve communication with PCPs to ensure communication of critical information and plans.

Methods

We assembled a multidisciplinary team and collected baseline data on discharge communication frequency and quality. We used quality improvement tools to implement a higher-quality system. The outcome measure was the successful delivery of a standardized notification and discharge summary to a PCP. We collected qualitative data through multidisciplinary meetings and direct feedback. The balancing measures comprised additional time spent during the discharge process and relaying erroneous information. We used a run chart to track progress and drive change.

Results

Baseline data indicated that 67% of PCPs did not receive notifications before discharge, and when PCPs did receive notifications, the discharge plans were unclear. PCP feedback led to proactive electronic communication and a standardized notification. The key driver diagram allowed the team to design interventions that led to sustainable change. After multiple Plan-Do-Study-Act cycles, delivery of electronic PCP notifications occurred more than 90% of the time. Surveys of pediatricians who received notifications indicated that the notifications were highly valued and aided in the transition of care for these at-risk patients.

Conclusion

A multidisciplinary team, including community pediatricians, was key to improving the rate of PCP notification of NICU discharge to more than 90% and transmitting higher-quality information.

Very-low-birth-weight infant short-term post-discharge outcomes: A retrospective study of specialized compared to standard care

OBJECTIVE

Ongoing health care challenges, low breast milk intake, and the need for rehospitalization are common during the first year of life after hospital discharge for very low birth weight (VLBW) infants. This retrospective cohort study examined breast milk intake, growth, emergency department (ED) visits, and non-surgical rehospitalizations for VLBW infants who received specialized post-discharge follow-up in western Canada, compared to VLBW infants who received standard follow-up in central Canada.

DESIGN

Data were collected from two neonatal follow-up programs for VLBW babies (n = 150 specialized-care; n = 205 standard-care). Logistic regression was used to examine odds of breast milk intake and generalized estimating equations were used for odds of growth, ED visits and non-surgical rehospitalization by site.

RESULTS

Specialized-care was associated with enhanced breast milk intake duration; the odds of receiving breastmilk at 4 months in the specialized-care cohort was 6 times that in the standard-care cohort. The specialized-care cohort had significantly more ED visits and rehospitalizations. However, for infants with oxygen use beyond 36 weeks compared to those with no oxygen use, the standard-care cohort had over 7 times the odds of rehospitalization where as the specialized-care cohort with no increased odds of rehospitalization.

CONCLUSION

Specialized neonatal nursing follow-up was associated with continued breastmilk intake beyond discharge. Infants in the specialized-care cohort used the ED and were hospitalized more often than the standard-care cohort with the exception of infants with long term oxygen needs.

Influence of different methods for calculating gestational age at birth on prematurity and small for gestational age proportions: a systematic review with meta-analysis

BACKGROUND

Recognizing premature newborns and small-for-gestational-age (SGA) is essential for providing care and supporting public policies. This systematic review aims to identify the influence of the last menstrual period (LMP) compared to ultrasonography (USG) before 24 weeks of gestation references on prematurity and SGA proportions at birth.

METHODS

Systematic review with meta-analysis followed the recommendations of the PRISMA Statement. PubMed, BVS, LILACS, Scopus-Elsevier, Embase-Elsevier, and Web-of-Science were searched (10-30-2022). The research question was: (P) newborns, (E) USG for estimating GA, (C) LMP for estimating GA, and (O) prematurity and SGA rates for both methods. Independent reviewers screened the articles and extracted the absolute number of preterm and SGA infants, reference standards, design, countries, and bias. Prematurity was birth before 37 weeks of gestation, and SGA was the birth weight below the p10 on the growth curve. The quality of the studies was assessed using the New-Castle-Ottawa Scale. The difference between proportions estimated the size effect in a meta-analysis of prevalence.

RESULTS

Among the 642 articles, 20 were included for data extraction and synthesis. The prematurity proportions ranged from 1.8 to 33.6% by USG and varied from 3.4 to 16.5% by the LMP. The pooled risk difference of prematurity proportions revealed an overestimation of the preterm birth of 2% in favor of LMP, with low certainty: 0.02 (95%CI: 0.01 to 0.03); I² 97%). Subgroup analysis of USG biometry (eight articles) showed homogeneity for a null risk difference between prematurity proportions when crown-rump length was the reference: 0.00 (95%CI: -0.001 to 0.000; I²: 0%); for biparietal diameter, risk difference was 0.00 (95%CI: -0.001 to 0.000; I²: 41%). Only one report showed the SGA proportions of 32% by the USG and 38% by the LMP.

CONCLUSIONS

LMP-based GA, compared to a USG reference, has little or no effect on prematurity proportions considering the high heterogeneity among studies. Few data (one study) remained unclear the influence of such references on SGA proportions. Results reinforced the importance of qualified GA to mitigate the impact on perinatal statistics.

TRIAL REGISTRATION

Registration number PROSPERO: CRD42020184646.

Family and Provider Experiences With Longitudinal Care Coordination for Infants With Medical Complexity

BACKGROUND

Parents in the neonatal intensive care unit (NICU) report low self-confidence managing their children's ongoing medical and social needs. While bedside nurses provide critical support for families throughout their NICU admission, there may be a role for nursing coordination throughout hospitalization, discharge, and in the transition to outpatient care.

PURPOSE

This program evaluation explores parent and provider experiences of a novel longitudinal care coordination program for infants with medical complexity from the NICU through their first year of life post-discharge.

METHODS

First, a sequential exploratory mixed-methods approach was used to evaluate parental experiences (n = 5 interviewed followed by n = 23 surveyed). Provider perspectives were elicited through semi-structured interviews (n = 8) and focus groups (n = 26 in 3 groups).

RESULTS

Parent-reported benefits included frequent communication and personalized support that met families' and patients' evolving needs. Care coordinators, who were trained as nurses and social workers, developed longitudinal relationships with parents. This seemed to facilitate individualized support throughout the first year of life. Providers reported that smaller caseloads were central to the success of the program.

IMPLICATIONS FOR PRACTICE AND RESEARCH

This longitudinal care coordination program can be used as a translatable model in NICUs elsewhere to address the unique needs of families of infants with medical complexity throughout the first year of life. Future implementations should consider how to expand program size while maintaining individualized supports. As the care coordinators are former NICU nurses and social workers, there may be a growing role for nursing coordination of care in the neonatal population.

High Healthcare Use at Age 5 Years in a European Cohort of Children Born Very Preterm

OBJECTIVES

To describe parent-reported healthcare service use at age 5 years in children born very preterm and investigate whether perinatal and social factors and the use of very preterm follow-up services are associated with high service use.

STUDY DESIGN

We used data from an area-based cohort of births at <32 weeks of gestation from 11 European countries, collected from birth records and parental questionnaires at 5 years of age. Using the published literature, we defined high use of outpatient/inpatient care (≥4 sick visits to general practitioners, pediatricians, or nurses, ≥3 emergency room visits, or ≥1 overnight hospitalization) and specialist care (≥2 different specialists or ≥3 visits). We also categorized countries as having either a high or a low rate of children using very preterm follow-up services at age 5 years.

RESULTS

Overall, 43% of children had high outpatient/inpatient care use and 48% had high specialist care use during the previous year. Perinatal factors were associated with high outpatient/inpatient and specialist care use, with a more significant association with specialist services. Associations with intermediate parental educational level and unemployment were stronger for outpatient/inpatient services. Living in a country with higher rates of very preterm follow-up service use was associated with lower use of outpatient/inpatient services.

CONCLUSIONS

Children born very preterm had high healthcare service use at age 5 years, with different patterns for outpatient/inpatient and specialist care by perinatal and social factors. Longer follow-up of children born very preterm may improve care coordination and help avoid undesirable health service use.

NICU discharge preparation and transition planning: guidelines and recommendations

In this section, we present Interdisciplinary Guidelines and Recommendations for Neonatal Intensive Care Unit (NICU) Discharge Preparation and Transition Planning. The foundation for these guidelines and recommendations is based on existing literature, practice, available policy statements, and expert opinions. These guidelines and recommendations are divided into the following sections: Basic Information, Anticipatory Guidance, Family and Home Needs Assessment, Transfer and Coordination of Care, and Other Important Considerations. Each section includes brief introductory comments, followed by the text of the guidelines and recommendations in table format. After each table, there may be further details or descriptions that support a guideline or recommendation. Our goal was to create recommendations that are both general and adaptable while also being specific and actionable. Each NICU's implementation of this guidance will be dependent on the unique makeup and skills of their team, as well as the availability of local programs and resources. The recommendations based only on expert opinion could be topics for future research.

Increased behavioral health needs and continued psychosocial stress among children with medical complexity and their families during the COVID-19 pandemic

Objective

Children with medical complexity (CMC) and their caregivers are at increased risk for multiple psychosocial stressors that can impact child and family well‐being and health outcomes. During the COVID‐19 pandemic, when access to supports diminished, psychosocial screening and integrated behavioral health (IBH) services in the primary care setting were crucial in identifying and addressing the unique needs of this population

Methods

Universal screening to identify psychosocial needs was implemented in a primary care clinic for CMC that includes IBH services. Data on the prevalence of psychosocial screening and IBH services for young children and their caregivers before and during the COVID‐19 pandemic were evaluated

Results

Psychosocial screening levels remained stable during the pandemic. Psychosocial needs were identified for 36% of screeners prior to the COVID‐19 pandemic and 33% during the COVID‐19 pandemic. The need for IBH services increased during the COVID‐19 time period resulting in a significant increase in IBH services

Conclusions

For CMC and their caregivers, psychosocial needs identified through psychosocial screening remained high during the pandemic, demonstrating the importance of screening for this population. The need for IBH services during the COVID‐19 pandemic increased, underscoring the value and demand for these services particularly during an unprecedented time.

A qualitative study of recorded telephone support calls with mothers of preterm infants: Expressing both positive and negative feelings

AIM

To describe the structure and content of telephone support calls between mothers of preterm infants and support team members after hospital discharge.

DESIGN

This is a qualitative study.

METHODS

Data consisted of 19 recordings of telephone calls that occurred between March 2013 and December 2015. The calls were made by support team members to mothers within two weeks of discharge from the neonatal unit. Analyses were performed using content analysis.

RESULTS

One category referred to what the support team members said that facilitated or did not facilitate the conversation. It was found that the support team members managed to have conversations that were tailored to the mother's current needs and conversations where the focus was on what the support team members thought was important. A second category referred to the topics the mothers talked about and that the mothers expressed both negative and positive feelings.

Underdiagnosis of obesity in pediatric clinical care settings among children born preterm: a retrospective cohort study

BACKGROUND

Neonatal care of preterm infants may include dietary approaches such as high calorie formulas to promote physical growth. However, continuing growth-promoting strategies beyond the point of necessity, coupled with poverty and food insecurity which are more common among families of children born preterm, may increase the risk of obesity. Because children born preterm tend to have more pressing health conditions that require ongoing care, obesity may go undiagnosed by providers.

METHODS

This retrospective cohort study included 38,849 children (31,548 term, 7301 preterm) born from 2010 to 2015, who received clinical care at a large pediatric medical center (Ohio, USA). Electronic medical record data, linked to Ohio birth certificates, were used to identify children with measured obesity (≥2 weight-for-length values ≥95th percentile before 24 months of age or BMI values ≥95th percentile at or after 24 months of age). Children were considered to have diagnosed obesity if their medical record had an obesity-related phrase or billing code recorded. Modified Poisson regression was used to compare risk of obesity undiagnosis among obese children born preterm versus at term.

RESULTS

In total, 13,697 children had measured obesity, 10,273 (75%) of which were undiagnosed. Children born preterm with measured obesity were 8% more likely to be undiagnosed compared to children born at term (adjusted relative risk = 1.08 95% CI 1.05, 1.11). The risk was slightly higher for preterm children born to white women or born to women with higher educational attainment. For both groups, Primary Care and subspecialist clinics were the most common settings for undiagnosed obesity (74.9% and 16.8% of undiagnosed cases, respectively).

CONCLUSIONS AND RELEVANCE

Preterm birth was associated with increased risk of undiagnosed obesity in early childhood. This highlights the need to enhance obesity screening in the preterm population and to further explore reasons for this disparity.

Coached, Coordinated, Enhanced Neonatal Transition (CCENT): protocol for a multicentre pragmatic randomised controlled trial of transition-to-home support for parents of high-risk infants

INTRODUCTION

Having an infant admitted to the neonatal intensive care unit (NICU) is associated with increased parental stress, anxiety and depression. Enhanced support for parents may decrease parental stress and improve subsequent parent and child outcomes. The Coached, Coordinated, Enhanced Neonatal Transition (CCENT) programme is a novel bundled intervention of psychosocial support delivered by a nurse navigator that includes Acceptance and Commitment Therapy-based coaching, care coordination and anticipatory education for parents of high-risk infants in the NICU through the first year at home. The primary objective is to evaluate the impact of the intervention on parent stress at 12 months.

METHODS AND ANALYSIS

This is a multicentre pragmatic randomised controlled superiority trial with 1:1 allocation to the CCENT model versus control (standard neonatal follow-up). Parents of high-risk infants (n=236) will be recruited from seven NICUs across three Canadian provinces. Intervention participants are assigned a nurse navigator who will provide the intervention for 12 months. Outcomes are measured at baseline, 6 weeks, 4, 12 and 18 months. The primary outcome measure is the total score of the Parenting Stress Index Fourth Edition Short Form at 12 months. Secondary outcomes include parental mental health, empowerment and health-related quality of life for calculation of quality-adjusted life years (QALYs). A cost-effectiveness analysis will examine the incremental cost of CCENT versus usual care per QALY gained. Qualitative interviews will explore parent and healthcare provider experiences with the intervention.

ETHICS AND DISSEMINATION

Research ethics approval was obtained from Clinical Trials Ontario, Children's Hospital of Eastern Ontario Research Ethics Board (REB), The Hospital for Sick Children REB, UBC Children's and Women's REB and McGill University Health Centre REB. Results will be shared with Canadian level III NICUs, neonatal follow-up programmes and academic forums.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03350243).

Discharge planning considerations for the neonatal intensive care unit

Neonatal intensive care unit (NICU) discharge readiness is the primary caregivers' masterful attainment of technical care skills and knowledge, emotional comfort and confidence with infant care by the time of discharge. NICU discharge preparation is the process of facilitating discharge readiness. Discharge preparation is the process with discharge readiness as the goal. Our previous work described the importance of NICU discharge readiness and strategies for discharge preparation from an American medical system perspective. NICU discharge planning is, however, of international relevance as challenges in relation to hospital discharge are a recurring global theme. In this manuscript, we conceptualise NICU discharge preparation with international perspective.

Discharge Age and Weight for Very Preterm Infants: 2005-2018

BACKGROUND

A complex set of medical, social, and financial factors underlie decisions to discharge very preterm infants. As care practices change, whether postmenstrual age and weight at discharge have changed is unknown.

METHODS

Between 2005 and 2018, 824 US Vermont Oxford Network member hospitals reported 314 811 infants 24 to 29 weeks' gestational age at birth without major congenital abnormalities who survived to discharge from the hospital. Using quantile regression, adjusting for infant characteristics and complexity of hospital course, we estimated differences in median age, weight, and discharge weight z score at discharge stratified by gestational age at birth and by NICU type.

RESULTS

From 2005 to 2018, postmenstrual age at discharge increased an estimated 8 (compatibility interval [CI]: 8 to 9) days for all infants. For infants initially discharged from the hospital, discharge weight increased an estimated 316 (CI: 308 to 324) grams, and median discharge weight z score increased an estimated 0.19 (CI: 0.18 to 0.20) standard units. Increases occurred within all birth gestational ages and across all NICU types. The proportion of infants discharged home from the hospital on human milk increased, and the proportions of infants discharged home from the hospital on oxygen or a cardiorespiratory monitor decreased.

CONCLUSIONS

Gestational age and weight at discharge increased steadily from 2005 to 2018 for survivors 24 to 29 weeks' gestation with undetermined causes, benefits, and costs.

The impact of different medical complications on the feasibility of removing the feeding tube from infants with dysphagia

PURPOSE

This study examined whether certain medical complications influence the feasibility of tube removal.

METHODS

42 subjects with dysphagia who were under the age of 2.5 years were nourished entirely through feeding tubes. Additionally, they were judged to have no aspiration. The following data about the infants were collected through a retroactive survey: age at which oral feeding training commenced, gender, and whether certain medical complications (cardiovascular, respiratory, digestive, neurological, or oral) had been present at birth. The data were analyzed to determine which type of medical complication affected the likelihood of removing the feeding tube from the infant at 3 years of age.

RESULTS

Of the five medical complications examined, cardiovascular complications significantly affected the feasibility of tube removal (p = 0.049).

CONCLUSION

Pediatric dysphagia patients with cardiac complications, compared to those with other complications, may take longer to transition off tube feeding.

Healthcare access and adverse family impact among U.S. children ages 0-5 years by prematurity status

BACKGROUND

Many children and their families are affected by premature birth. Yet, little is known about their healthcare access and adverse family impact during early childhood. This study aimed to (1) examine differences in healthcare access and adverse family impact among young children by prematurity status and (2) determine associations of healthcare access with adverse family impact among young children born prematurely.

METHODS

This was a secondary analysis of cross-sectional 2016 and 2017 National Survey of Children's Health data. The sample included 19,482 U.S. children ages 0-5 years including 242 very low birthweight (VLBW) and 2205 low birthweight and/or preterm (LBW/PTB) children. Prematurity status was defined by VLBW (i.e., < 1500 g at birth) and LBW/PTB (i.e., 1500-2499 g at birth and/or born at < 37 weeks with or without LBW). Healthcare access measures were adequate health insurance, access to medical home, and developmental screening receipt. Adverse family impact measures were ≥ $1000 in annual out-of-pocket medical costs, having a parent cut-back or stop work, parental aggravation, maternal health not excellent, and paternal health not excellent. The relative risk of each healthcare access and adverse family impact measure was computed by prematurity status. Propensity weighted models were fit to estimate the average treatment effect of each healthcare access measure on each adverse family impact measure among children born prematurely (i.e., VLBW or LBW/PTB).

RESULTS

Bivariate analysis results showed that VLBW and/or LBW/PTB children generally fared worse than other children in terms of medical home, having a parent cut-back or stop working, parental aggravation, and paternal health. Multivariable analysis results only showed, however, that VLBW children had a significantly higher risk than other children of having a parent cut-back or stop work. Adequate health insurance and medical home were each associated with reduced adjusted relative risk of ≥$1000 in annual out-of-pocket costs, having a parent cut-back or stop work, and parental aggravation among children born prematurely.

CONCLUSIONS

This study's findings demonstrate better healthcare access is associated with reduced adverse family impact among U.S. children ages 0-5 years born prematurely. Population health initiatives should target children born prematurely and their families.

Development of a Multidisciplinary Medical Home Program for NICU Graduates

OBJECTIVE

Typical primary care practices are often not equipped to meet the medical, developmental or social needs of infants discharged from a neonatal intensive care unit (NICU). These needs are exacerbated for infants and caregivers residing in poverty. This article discusses a multidisciplinary, family-centered medical home designed to address the needs of this special population.

METHODS

This is a descriptive analysis of a cohort of patients in the Next Steps Program (NSP), a multidisciplinary primary care medical home. Key program elements include: continuity of care from the NICU to primary care, routine developmental surveillance, care coordination, and proactive screening to address medical and social needs.

RESULTS

The NSP has become a primary referral source for local NICUs, with a total of 549 medically fragile infants enrolled from its inception in 2011 through 2016. Caregivers and patients experience psychosocial stressors at averages statistically significantly higher than the rest of the Commonwealth of Pennsylvania and the US. Although patients in the program use medical resources beyond that of typically developing infants, hospital utilization among this patient cohort is trending down.

DISCUSSION

Caring for medically fragile NICU graduates can be daunting for families given the array of necessary services, supports, and resources to maximize their potential. A multidisciplinary primary care medical home, such as the NSP, is a successful model of patient care demonstrating favorable associations with health care utilization, care coordination, and addressing/improving family functioning and their experience.

Transition From Hospital to Home in Parents of Preterm Infants: Revision, Modification, and Psychometric Testing of the Questionnaire

BACKGROUND AND PURPOSE

Transition from hospital to home in parents of prematurely born infants can be challenging. This methodological study aimed to develop an instrument to measure transitional problems in parents after hospital discharge.

METHODS

Kenner's Transition Questionnaire was modified based on findings of the literature review and a qualitative study. Content validity of the revised tool was determined by a panel of experts, and field testing was conducted via an online survey of parents of preterm infants (N = 704). Exploratory factor analysis (principal axis factoring and direct oblimin rotation) was performed.

RESULTS

Results showed four correlated factors in parental transition from hospital to home: Isolation, Worry, Confidence, and Professional Support (17 items total). Factor loadings ranged from .59 to .87, and reliability estimates ranged from .77 to .87.

CONCLUSION

The revised instrument demonstrated adequate psychometric characteristics; further testingand validation of the instrument is warranted.

Preterm infants are less likely to have a family-centered medical home than term-born peers

OBJECTIVE

The family-centered medical home (FCMH) is the recommended healthcare delivery model for children. It is unknown how frequently preterm (PT) children receive care in a FCMH and how this affects health services use.

STUDY DESIGN

We studied 18,397 children aged 0-3 years in the 2010/2011 National Survey of Children's Health. We compared PT (<37 weeks) and full-term (FT) children on rates of FCMH and receiving prescribed health services. Regression models included sex, race, income, insurance status, and having a special health care need (SHCN).

RESULTS

PT children were significantly less likely to have a FCMH (57% vs. 66%) compared to FT peers despite higher rates of SHCN (16% vs. 5%). PT children were less likely to receive prescribed services (aOR 0.34, 95% CI 0.34, 0.34); lacking a FCMH explained 69% of this effect.

CONCLUSIONS

Ensuring PT children have access to medical homes may decrease unmet service needs post-hospital discharge.

Beyond bus fare: deconstructing prenatal care travel among low-income urban mothers through a mix methods GIS study

OBJECTIVE

Guided by critical theory, this study illustrates the value of interpretative mapping to deconstruct bus travel to publicly funded prenatal care in a city marked by health and social inequities.

METHODS

This mixed methods study used GIS maps based on 61,305 births to study the known barrier of transportation to prenatal care among urban mothers most at risk for preterm birth.

RESULTS

Among 350 census tracts, 36 census tracts had preterm rates between 25 -36.9%. Modeling travel time for the case vignette for routine prenatal care took 21 visits to different geographically located facilities. This burden increased to 32 visits if the case vignette was high-risk.

CONCLUSIONS

Interpretative GIS mapping is an important tool to ground truth spatially linked data into real world meanings. Promoting optimal health requires innovative and feasible approaches that take into consideration daily maternal functioning as pregnant mothers care for their children and themselves.

ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Home Visiting and the Health of Preterm Infants

The results of home visiting programs which target medically fragile low-birth-weight preterm infants (LBWPT) have been inconsistent. We provided nurse/social worker home visits to families of LBWPT infants on a regular schedule. Teams were trained in approaches to improve the health and development of the infants. The completion of immunization series was sigmificantly higher and the infant mortality rates of the home visits childen were significanly lower compared to national and state rates. We used state Medicaid data and examined frequency of hospitalization, emergency department visits, routine and nonscheduled visits to primary care physician, and pharmacy use of the home-visited subjects compared with a propensity-matched group. The home-visited group had more routine and nonscheduled visits but no more hospitalizations or E.D. visits. Home visiting teams improved important markers of child health, including completed immunizations and mortality rate, perhaps by the careful monitoring of health status and assuring health care when needed.