Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study.

OBJECTIVES: We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator. SETTING: We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011. PARTICIPANTS: The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors. INTERVENTIONS: No interventions were made. OUTCOME MEASURES: The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes. RESULTS: In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients' age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=-0.15 (p>0.05)). CONCLUSIONS: The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.

[The impact of a premature birth on the family; consequences are experienced even after 19 years]. / Impact van vroeggeboorte op het gezin: ook na 19 jaar ondervinden families nog gevolgen.

OBJECTIVE: A premature birth can cause parental stress, anxiety and uncertainty. This study illustrates the long-term consequences of a preterm birth for family life. DESIGN: Retrospective study by questionnaire. METHOD: Parents of 959 children, who were born in 1983 with a gestational age of less than 32 weeks or a birth weight of less than 1500 grams, were approached when their children turned 19 years old. We investigated various aspects of their family lives by means of a written questionnaire. RESULTS: We received completed questionnaires back from 595 parents (62%). The divorce rate was higher in families with a disabled child (26 vs. 14%). Working mothers (n = 257) and fathers (n = 506) experienced negative consequences in their workplace (36% and 2%, respectively). The risk factor was having a handicapped child. Financial problems were present in 11% of the families during the first year and 4% still experienced financial problems after 19 years; risk factors were a handicap, male gender and a low social-economic status (SES) of the parents. Of the respondents, 26% had observed a decrease in social activities and friends during the first year and 15% felt that family and friends provided insufficient support during this year. After 19 years, 4% of the respondents still experienced a negative influence on their social lives. Risk factors were a handicap, normal birth weight (no dysmaturity), male gender and low SES. 28% of parents expressed that during the first year having a preterm child was emotional challenging or difficult to accept. After 19 years, 3% still expressed an unfavourable effect of the preterm birth. Risk factors were handicap, dysmaturity and male gender. CONCLUSION: A premature birth has a great impact on the family, especially when the child has a handicap.

Classifying indicators of quality: a collaboration between Dutch and English regulators.

INTRODUCTION: Many approaches to measuring quality in healthcare exist, generally employing indicators or metrics. While there are important differences, most of these approaches share three key areas of measurement: safety, effectiveness and patient experience. The European Partnership for Supervisory Organisations in Health Services and Social Care (EPSO) exists as a working group and discussion forum for European regulators. This group undertook to identify a common framework within which European approaches to indicators could be compared. APPROACH: A framework was developed to classify indicators, using four sets of criteria: conceptualization of quality, Donabedian definition (structure, process, outcome), data type (derivable, collectable from routine sources, special collections, samples) and data use (judgement (singular or part of framework) benchmarking, risk assessment). Indicators from English and Dutch hospital measurement programmes were put into the framework, showing areas of agreement and levels of comparability. In the first instance, results are only illustrative. CONCLUSIONS AND IMPLICATIONS: The EPSO has been a powerful driver for undertaking cross-European research, and this project is the first of many to take advantage of the access to international expertize. It has shown that through development of a framework that deconstructs national indicators, commonalities can be identified. Future work will attempt to incorporate other nations' indicators, and attempt cross-national comparison.

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.

School performance in adolescents with and without periventricular-intraventricular hemorrhage in the neonatal period.

Long-term sequelae of preterm birth have been studied extensively up until the age of 5 to 8 years. However, the cognitive development of adolescents born preterm has received limited attention. The objective of this study is to determine school performance in adolescents born very preterm. We have followed up a cohort of 484 infants born before 32 weeks of gestation in whom cranial ultrasound was routinely and systematically performed. School performance was assessed in the surviving adolescents at 14 years of age. The outcome variable divided the adolescents into three groups: (1) normal, (2) slow learners, and (3) special education. School performance data were obtained from 278 of 304 surviving adolescents; 129 performed normally, while 107 were slow learners, and 42 needed special education. From the unadjusted odds ratios for the need of special education by the various perinatal factors, only the odds ratio for periventricular-intraventricular hemorrhage was significantly associated (2.56, 95% confidence interval 1.17-4.86). Logistic regression analysis revealed that, after correction for possible confounding factors, the odds ratios for special education were significantly higher for adolescents with all grades of periventricular-intraventricular hemorrhage. Less than 50% of adolescents born before 32 weeks gestation perform normally in school. Periventricular-intraventricular hemorrhage, including the lower grades,does have an unfavorable additional effect on school performance.

School-age outcomes in children who were extremely low birth weight from four international population-based cohorts.

OBJECTIVE: The aim of this study was to determine whether learning and school problems in extremely low birth weight (ELBW) and reference children differ between cohorts in different countries. METHODS: Participants were 4 international population-based cohorts of ELBW survivors who were 500 to 1000 g birth weight from New Jersey, central-west Ontario, Bavaria, and Holland (n = 532) and were followed longitudinally from birth. Psychometric data were collected independently and prospectively and included at least 1 measure of cognitive status and 1 measure of achievement administered to the children between the ages of 8 and 11 years. Adjustments were made for comparison of all measures based on reference norms within each country. Information on special educational assistance and grade repetition was obtained from the parents. RESULTS: The overall follow-up rate was 84% (range: 74%-90%; n = 436). The proportion of children who performed within the normal range (> or =85) were as follows: IQ between 44% and 62%; reading between 46% and 81%; arithmetic between 31% and 76%; and spelling between 39% and 65%. Children from New Jersey had the lowest rates of cognitive and achievement deficits, and Bavarian children did less well in achievement scores relative to their peers and other cohorts. Despite these differences, more than half of all cohorts required special educational assistance and/or repeated a grade. CONCLUSIONS: School difficulties were found to be a serious sequelae of ELBW in all 4 countries, an observation that has social and economic implications.

Reliability of classification of cerebral palsy in low-birthweight children in four countries.

The reliability of classification of cerebral palsy (CP) in low-birthweight children was assessed by using clinical and research study records sampled from population-based cohort studies in the USA, The Netherlands, Canada, and Germany. Records of neurological examination findings and functional motor assessments were submitted to up to five pediatricians with expertise in CP diagnosis, who grouped children into categories referred to as 'disabling' CP, 'non-disabling' CP, and no CP. Each study provided between 31 and 51 records of children assessed between 2 and 8 years of age, approximately equally divided among the three groupings. The discrimination between 'any CP' and 'no CP' was only fair (mean Kappa coefficients 0.37 to 0.69). However, when more detailed information describing motor function was used, children with 'disabling' CP could be distinguished, on the basis of records, from those without CP or with 'non-disabling' CP with good to excellent reliability (mean Kappa coefficients 0.69 to 0.88). Because of the substantially higher agreement observed when these functional distinctions are made, we recommend that reports or comparisons of rates of CP should include levels of motor function of children with CP, and not simply total CP, among the outcomes of interest.