Variation in diagnosis of apnea in moderately preterm infants predicts length of stay.

OBJECTIVE: Apnea of prematurity is one of the most common diagnoses in the NICU. Because resolution of apnea is a usual precondition for discharge from the hospital, different monitoring practices might affect length of stay for premature infants. Our objective was to compare the proportion of 33 to 34 weeks' gestational age infants diagnosed with apnea in different NICUs and to assess whether variability in length of stay would be affected by the rate of documented apnea. METHODS: This was a prospective cohort study of moderately preterm infants who survived to discharge in 10 NICUs in Massachusetts and California. RESULTS: The study population comprised 536 infants born between 33 and 34/7 weeks of which 264 (49%) were diagnosed with apnea. The mean postmenstrual age at discharge was higher in infants diagnosed with apnea compared with those without apnea (36.4 ± 1.3 vs 35.7 ± 0.8; P < .001, analysis of variance). Significant inter-NICU variation existed in the proportion of infants diagnosed with apnea (range: 24%-76%; P < .001). Postmenstrual age at discharge also varied between NICUs (range: 35.5 ± 0.6 to 36.7 ± 1.5 weeks; P < .001). As much as 28% of the variability in postmenstrual age at discharge between NICUs could be explained by the variability in the proportion of infants diagnosed with apnea. CONCLUSIONS: NICUs vary in the proportion of moderately preterm infants diagnosed with apnea, which significantly affects length of stay. Standardization of monitoring practices and definition of clinically significant cardiorespiratory events could have a significant impact on reducing the length of stay in moderately preterm infants.

Factors influencing parental satisfaction with neonatal intensive care among the families of moderately premature infants.

OBJECTIVE: The goal was to examine the factors influencing parental satisfaction with neonatal intensive care for moderately premature infants in 10 hospitals in Massachusetts and California. METHODS: A total of 677 infants without major anomalies or chromosomal disorders who were born between 30 and 34 weeks of gestation in the participating hospitals and discharged alive were included. Parental satisfaction with neonatal intensive care was ascertained 3 months after discharge by using a previously developed scale of 12 Likert items (scored 1-5), addressing such issues as perceptions regarding the staff providing emotional support, information, or education. The questionnaire, which was administered by telephone, also included parental ratings of child health and reports of subsequent health care use, sociodemographic characteristics, and history of infertility treatment. Data on the prenatal, perinatal, and neonatal course were abstracted from the medical charts, and the factors associated with parental satisfaction were analyzed. RESULTS: Parental satisfaction with neonatal intensive care varied significantly across the 10 hospitals. The major predictors of satisfaction were sociodemographic characteristics, history of infertility treatment, and especially parental ratings of child health 3 months after discharge, rather than aspects of the perinatal or neonatal course. Controlling for these factors, differences across hospitals were not statistically significant. However, the variance explained by all of the measured factors, including child health rating, was modest (19%). CONCLUSIONS: Although we included variables across the full spectrum of neonatal intensive care, we found that the major predictor of parental satisfaction with neonatal intensive care was child health at the time of the interview, followed by sociodemographic factors and previous infertility treatment. However, the variance explained was limited, which suggests that research is needed on the factors influencing satisfaction.

Neonatal intensive care unit census influences discharge of moderately preterm infants.

OBJECTIVE: The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants. DESIGN/METHODS: In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge. RESULTS: There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates. CONCLUSIONS: Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.

Revalidation of the Score for Neonatal Acute Physiology in the Vermont Oxford Network.

OBJECTIVES: Our specific objectives were (1) to document the performance of the revised Score for Neonatal Acute Physiology and the revised Score for Neonatal Acute Physiology Perinatal Extension in predicting death in the Vermont Oxford Network, compared with published normative values; (2) to determine whether this performance could be improved through recalibration of the weights for individual score items; (3) to determine the impact of including congenital anomalies in the predictive model; and (4) to compare performance against that of the Vermont Oxford Network risk adjustment, separately and in combination. METHODS: Fifty-eight Vermont Oxford Network centers collected data prospectively for the revised Score for Neonatal Acute Physiology in the first 12 hours after admission of infants in 2002. RESULTS: Data were collected for 10,469 infants, and analyses were undertaken for 9897 who met inclusion criteria. The median revised Score for Neonatal Acute Physiology was 5, and the mean birth weight was 1951 g. Recalibration of the revised Score for Neonatal Acute Physiology and revised Score for Neonatal Acute Physiology Perinatal Extension resulted in minimal changes in their discriminatory abilities. The Vermont Oxford Network risk adjustment performed similarly, compared with the revised Score for Neonatal Acute Physiology Perinatal Extension. CONCLUSIONS: Current score performance was similar to that observed previously, which suggests that the revised Score for Neonatal Acute Physiology and revised Score for Neonatal Acute Physiology Perinatal Extension have not decalibrated over the 7 years since the first cohort was assembled, despite advances in neonatal care during that period. Addition of congenital anomalies to the revised Score for Neonatal Acute Physiology Perinatal Extension improved discrimination significantly, particularly for infants with birth weights of >1500 g. The Vermont Oxford Network risk adjustment performed similarly, compared with the revised Score for Neonatal Acute Physiology Perinatal Extension.

Place of birth and variations in management of late preterm ("near-term") infants.

BACKGROUND: The purpose of this study is to characterize variations in management late preterm infants because such variations in such a large group of neonates would have economic and health implications. METHODS: Comparison of the use of illustrative management approaches and gestational age at discharge among infants born at 33 to 34 6/7 weeks and discharged alive from 10 Massachusetts and California NICUs. RESULTS: Generally similar in birth weight and admission severity, significant differences were seen in illustrative interventions, such as the use of mechanical ventilation (range in use across hospitals from 9% to 43%) and nutritional practices (use of hyperalimentation ranged from 5% to 66%). Variations in average daily weight gain were seen with some infants averaging net losses. Postmenstrual age at discharge varied by a week between the hospital with the earliest discharge and that with the latest. CONCLUSIONS: Care for these infants would be improved by further examination of their needs and the establishment of practice guidelines to reduce unneeded variation.

Retrospective economic evaluation of a controlled trial of indomethacin prophylaxis for patent ductus arteriosus in premature infants.

OBJECTIVE: To determine the incremental cost-effectiveness of indomethacin prophylaxis in extremely low birth weight infants enrolled in the Trial of Indomethacin Prophylaxis in Preterms (TIPP). STUDY DESIGN: Participants in this economic evaluation were 428 infants enrolled at 9 Canadian TIPP centres. The study took a third-party payer perspective. Prior to the analysis of clinical trial data, direct medical costs were derived from chart review of 89 items of resource utilization, for each day from admission to hospital discharge. Unit costs for each resource were obtained from a provincially standardized cost-accounting system. Incremental cost-effectiveness analysis was performed, with estimation of cost-effectiveness acceptability curves through non-parametric bootstrapping. RESULTS: The mean (SD) cost was $68,279 (40,317) for the placebo group and $69,629 (37,989) for the indomethacin group. Indomethacin prophylaxis cost an additional $67,500 per death or impairment averted. However, the precision of this estimate was low, such that the probability that the estimate was lower than $300,000 per death or impairment averted was only 61%. The results were similar when surgical costs were assumed to be 500% of those measured in the trial. CONCLUSIONS: This study does not provide an economic rationale for the use of indomethacin prophylaxis in ELBW infants.

Dietitian involvement in the neonatal intensive care unit: more is better.

OBJECTIVE: Describe the level of registered dietitian (RD) involvement in neonatal intensive care units (NICUs) and associations with NICU nutrition practices. DESIGN: Questionnaires were mailed to 820 NICUs in the United States with two follow-up mailings to nonresponders. Abbreviated phone surveys were conducted with a random sample of 10% of nonresponders. A nutrition care score was devised based on a sum of 10 survey questions (range 0 to 10) to summarize the intensity of reported practices. SUBJECTS/SETTING: Directors of NICUs in the United States and RDs associated with them. STATISTICAL ANALYSES: Chi2, analysis of variance, Bonferroni and Duncan multiple range tests, regression. RESULTS: Respondents from 417 (54%) of the 772 NICUs eligible for the study provided completed questionnaires. Among NICUs responding, 76% involved RDs in care (41% employed full- or part-time RDs, 35% employed consult RDs), and 24% had no RD. NICUs with full- or part-time RDs provided fewer kilocalories and more protein parenterally, and more kilocalories and protein enterally. NICUs with less RD involvement were more likely to provide full-term infant feedings (eg, unfortified breast milk, full-term formula) to very-low-birth-weight infants. Mean nutrition care score varied with RD involvement from 4.6+/-1.7 (mean+/-standard deviation) for NICUs with a consult RD and 4.7+/-1.4 for NICUs employing no RD to 5.6+/-1.7 for NICUs with a full- or part-time RD (overall P<.001). CONCLUSIONS: More involvement of RDs in NICUs increased the intensity of important aspects of nutrition care that may improve outcomes of very-low-birth-weight infants in NICUs. These findings highlight the importance of RDs as NICU team members.

Prenatal consultation practices at the border of viability: a regional survey.

OBJECTIVE: We undertook a survey of all practicing neonatologists in New England to determine their attitudes and practices regarding prenatal consultations for infants at the border of viability. METHODS: A self-administered anonymous survey, mailed to every practicing neonatologist in the 6 Northeast states of Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont, explored respondent attitudes and practices with respect to a hypothetical clinical scenario of a prenatal consultation for an infant at the border of viability. RESULTS: Our final sample included 149 surveys from 175 eligible neonatologists, giving a response rate of 85%. Seventy-seven percent of respondents indicated that they thought neonatologists and parents should make the decision jointly to withhold resuscitation. Only 40% indicated that the decision actually is made by both parties. A majority of neonatologists (58%) saw their primary role during the prenatal consultation as providing factual information to the parents. Far fewer (27%) thought that their main role was to assist the parents in weighing the risks and benefits of various management options. A majority of respondents indicated that parental understanding of the mother's current medical situation (96%), desired parental role (77%), and parental prior experience with premature or handicapped children (64%) were frequently or always discussed. However, far fewer respondents reported frequently or always asking about parental interpretations of a "good quality of life" (42%), parental prior experiences with death or dying (30%), and parental religious or spiritual beliefs (25%). Short-term outcomes and complications such as the need for surfactant/respiratory distress syndrome (89%) and the risk of intraventricular hemorrhage (81%) were discussed more extensively than long-term outcomes such as motor delays or cerebral palsy (68%), cognitive delays or learning disabilities (63%), and chronic lung disease (61%). Multivariate logistic regression analysis revealed 2 characteristics that were significant predictors of shared decision-making for the final decision regarding resuscitation in the delivery room for extremely premature infants, ie, believing that the main role of the neonatologist during prenatal consultations is to help parents weigh the risks and benefits of each resuscitation option (odds ratio: 4.1; 95% confidence interval: 1.6-10.9) and having >10 years of clinical experience (odds ratio: 3.6; 95% confidence interval: 1.5-8.8). CONCLUSIONS: Overall, our results showed that neonatologists are quite consistent in discussing clinical issues but quite varied in discussing social and ethical issues. If neonatologists are to perform complete prenatal consultations for infants at the border of viability as described by the latest American Academy of Pediatrics guidelines, then they will be expected to address quality-of-life values more robustly, to explain long-term outcomes, and to incorporate parental preferences during their conversations. Potential barriers to shared decision-making have yet to be outlined.

Interneonatal intensive care unit variation in growth rates and feeding practices in healthy moderately premature infants.

BACKGROUND: Variation in care and outcomes of very low birth weight infants (VLBW) in neonatal intensive care units (NICU) has been widely reported in the past decade. Less is known about care provided to healthy premature infants born between 30 and 35 weeks gestational age (GA). We have previously reported inter-NICU variation in discharge (D/C) timing and achievement of maturational milestones in this population. OBJECTIVE: To compare inter-NICU growth outcomes and feeding practices in healthy, moderately premature infants. METHODS: Records of 450 infants, 30 to 35 weeks gestation, without medical or surgical complications, and consecutively discharged from 15 Massachusetts NICUs (nine Level II and six Level III) were reviewed. Final analyses included 382 infants with hospital length of stay >6 days (d). RESULTS: GA at birth and birth weight (BW) were 33.2 weeks (SD 1.2) and 2024 g (389). Mean Z-score decreased 0.67z (0.37) from birth to D/C. Weight loss from birth to 7 d averaged 4.0%. Mean growth velocity from 7 d to D/C was 13.3 g/k/d (5.2) with net growth velocity of 5.5 g/k/d (5.6). Mean net growth velocity ranged from 0.1 to 8.4 g/k/d (p<0.001) among study NICUs. Time of initiation, rate of advancement and caloric density of feedings also varied significantly between NICUs. CONCLUSION: Mean NICU growth velocity of healthy, moderately premature infants did not achieve in utero growth standards. There was significant inter-NICU variation in growth outcomes and feeding practices. Further study is needed to identify practices associated with better growth in this healthy moderately premature infant population.

Trends in severe bronchopulmonary dysplasia rates between 1994 and 2002.

OBJECTIVE: To examine temporal trends in the rates of severe bronchopulmonary dysplasia (BPD) between 1994 and 2002. STUDY DESIGN: In a retrospective cohort study, all infants with a gestational age (GA) <33 weeks in a large managed care organization were identified. Annual rates of BPD (defined as an oxygen requirement at 36 weeks corrected GA), severe BPD (defined as respiratory support at 36 weeks corrected GA), and death before 36 weeks corrected GA were examined. RESULTS: Of the 5115 infants in the study cohort, 603 (12%) had BPD, including 246 (4.9%) who had severe BPD. There were 481 (9.5%) deaths before 36 weeks corrected GA. Although the decline in BPD in this period was not significant, the rates of severe BPD declined from 9.7% in 1994 to 3.7% in 2002. Controlling for gestational age, the odds ratio (95% CI) for annual rate of decline in severe BPD was 0.890 (0.841-0.941). Controlling for gestational age, deaths before 36 weeks corrected GA also declined, with the odds ratio (CI) for the annual decline being 0.944 (0.896-0.996). CONCLUSIONS: In this study population, the odds of having of BPD remained constant after controlling for GA. However, the odds of having severe BPD declined on average 11% per year between 1994 and 2002.

Delivery room decision-making at the threshold of viability.

OBJECTIVES: To assess attitudes of neonatologists toward parental wishes in delivery room resuscitation decisions at the threshold of viability. STUDY DESIGN: Cross-sectional survey of the 175 practicing level II/III neonatologists in six New England states. RESULTS: Response rate was 85% (149/175). At 24 1/7-6/7 weeks' gestation, 41% of neonatologists considered treatment clearly beneficial, and at 25 1/7-6/7 weeks' gestation, 84% considered treatment clearly beneficial. When respondents consider treatment clearly beneficial, 91% reported that they would resuscitate in the delivery room despite parental requests to withhold. At or below 23 0/7 weeks' gestation, 93% of neonatologists considered treatment futile. Thirty-three percent reported that they would provide what they consider futile treatment at parental request. When respondents consider treatment to be of uncertain benefit, all reported that they would resuscitate when parents request it, 98% reported that they would resuscitate when parents are unsure, and 76% reported that they would follow parental requests to withhold. CONCLUSIONS: Variation in neonatologists' beliefs about the gestational age bounds of clearly beneficial treatment and attitudes toward parental wishes in the context of uncertainty is likely to impact the manner in which they discuss options with parents before delivery. This supports the importance of transparency in neonatal decision-making.

Rehospitalization in the first year of life among infants with bronchopulmonary dysplasia.

OBJECTIVE: To describe rates and identify risk factors for rehospitalization during the first year of life among infants with bronchopulmonary dysplasia (BPD). STUDY DESIGN: This was a retrospective cohort study of infants born at a gestational age (GA) <33 weeks, between 1995 and 1999. BPD was defined as requirement of supplemental oxygen and/or mechanical ventilation at 36 weeks' corrected GA. The outcome was rehospitalization for any reason before first birthday. RESULTS: In the first year of life, 118 of 238 (49%) infants with BPD were rehospitalized, more than twice the rate of rehospitalization of the non-BPD population, which was 309 of 1359 (23%) (P=<.0001). No measured factor discriminated between those infants with BPD who were and were not rehospitalized, even when only rehospitalizations for respiratory diagnoses were considered. CONCLUSIONS: Among premature infants, BPD substantially increases the risk of rehospitalization during the first year of life. Neither demographic nor physiologic factors predicted rehospitalization among the infants with BPD. Other factors, such as air quality of home environment, passive smoking exposure, respiratory syncytial virus prophylaxis, breast-feeding status, and/or parenting and primary care management styles, should be examined in future studies.

The impact of early transfer bias in a growth study among neonatal intensive care units.

BACKGROUND AND OBJECTIVE: Transfer of infants between hospitals or their discharge home may bias comparisons of the performance across neonatal intensive care units (NICUs). This study attempts to show the potential size of transfer bias in the context of a large cohort study and describe strategies for minimizing this type of bias. METHODS: To limit transfer bias in a neonatal growth study of extremely premature infants in six tertiary NICUs, we restricted eligibility to infants <30 weeks gestation at birth and substituted matched replacements for early transfers (infants transferred or discharged prior to day of life 16). RESULTS: The restriction strategy was successful, reducing the overall early transfer rate from 16.4 to 3.6% and the range of transfer rates among individual NICUs from 0.6-32.7% to 0-11.0%. Replacement by matched substitutes had a much smaller effect because of the small number of early transfers and our inability to match on all factors distinguishing early transfers. CONCLUSION: Sampling strategies to minimize infants lost to follow-up were more successful than replacement strategies in limiting transfer bias in a NICU growth study. Although complete elimination of bias is likely impossible, valid studies require efforts to minimize, quantify, and test the effect of transfer bias.

Daily cost prediction model in neonatal intensive care.

OBJECTIVES: One barrier to economic evaluation alongside neonatal randomized controlled trials is the expense of collecting detailed patient resource information. To reduce this data collection burden, we identified the key resource items that predict daily ancillary costs for extremely low birth weight infants. METHODS: Participants were 385 infants enrolled in the Trial of Indomethacin Prophylaxis for Preterms in nine tertiary level neonatal intensive care units in Canada. Information on eighty-nine nonpersonnel resource items was abstracted from the hospital chart from admission to tertiary hospital discharge. Unit costs were derived from a provincially standardized cost accounting system. Using stepwise linear regression, models correlating total daily ancillary costs with key resource items were constructed for each of five periods of admission. Models were derived in a randomly split half of the total sample of patient days and validated against the remainder. RESULTS: The 385 infants contributed resource information from 23,354 admission days. The regression model for weeks one to twelve included the covariates surfactant, chest radiograph, red blood cell transfusion, cranial ultrasound, abdominal radiograph, parenteral amino acid infusion, surgery, platelet transfusion, and echocardiogram and explained 91% of the variability in daily nonpersonnel costs (P<.0001). Models for other admission periods similarly included between four and eight covariates, were highly significant (P<.0001) and explained between 76% and 94% of daily ancillary cost variability. The regression equations showed excellent predictive power when applied to the second half of the patient data set. CONCLUSIONS: Daily nonpersonnel costs for extremely low birth weight infants are driven by a limited number of key resource variables. The ability to predict total ancillary costs with minimal data collection will facilitate inclusion of economic evaluations in neonatal trials.

Inter-NICU variation in rates and management of thrombocytopenia among very low birth-weight infants.

OBJECTIVES: To investigate variation among neonatal intensive care units (NICUs) in prevalence and management of thrombocytopenia in infants <1500 g. STUDY DESIGN: In total 1283 infants &<1500 g admitted to six NICUs over 21 months were prospectively analyzed. Illness severity was measured by the Score for Neonatal Acute Physiology (SNAP). Platelet counts in the first 12 hours after birth and on day 3 of life were abstracted from the infants' medical records. Thrombocytopenia was determined from the lowest platelet count in each of these time periods. RESULTS: There was variability in rates of thrombocytopenia among NICUs, even after controlling for risk factors (e.g., SNAP, small for gestational (SGA) age and maternal hypertension). One site had a high prevalence of thrombocytopenia, but the lowest percentage of infants with thrombocytopenia who received platelet transfusions. After controlling for SNAP, GA, SGA, Apgar score and incidence of thrombocytopenia, the odds of receiving platelets at this site, relative to the site with the highest transfusion rate, was 0.10 (95% CI 0.02 to 0.43). CONCLUSIONS: This multicenter study finds a 10-fold variation among NICU in the administration of platelets to their thrombocytopenic infants that cannot be explained by presence of thrombocytopenia or illness severity.

Cost-effectiveness analysis of predischarge monitoring for apnea of prematurity.

OBJECTIVE: It is standard practice to defer discharge of premature infants until they have achieved a set number of days without experiencing apnea. The duration of this period, however, is highly variable across institutions, and there is scant literature on its effectiveness or value-for-money. Our objective was to establish the economic impact of varying durations of predischarge observation for apnea of prematurity. METHODS: Using computer simulation, we compared the alternatives of hospital monitoring for 1 to 10 days, after apparent cessation of apnea, with no monitoring and with the next longest period of monitoring. The daily probability of apnea requiring stimulation after a given number of apnea-free days was obtained from chart review of 216 infants, beginning on the day they attained both full feeds and temperature stability in an open crib. Baseline rates of survival or impairment, utilities for calculation of quality-adjusted life years (QALYs), outcomes for respiratory arrest at home, and long-run costs for neurodevelopmental impairment were derived from the literature. Hospital expenditures were obtained from itemized billing records for infants on each of the final 10 days of hospitalization and converted to costs using Medicare cost-to-charge ratios. Costs are reported in 2000 US dollars. RESULTS: For infants born at 24 to 26 weeks' gestation, each additional day of monitoring cost from $41000 per QALY saved for the first day to >$130000 per additional QALY gained for the tenth day. Cost-effectiveness was poorer for infants who were born at gestational ages >30 weeks. Results were sensitive to the proportion of charted apneas requiring stimulation that would actually progress, without intervention, to respiratory arrest. CONCLUSIONS: In this model, the cost-effectiveness of predischarge monitoring for apnea of prematurity declined significantly as the duration of monitoring was increased. Consideration should be given to alternative uses for resources in formulating neonatal discharge guidelines.

Characterization of neonatal personnel time inputs and prediction from clinical variables--a time and motion study.

OBJECTIVE: To characterize and predict personnel time inputs to neonatal intensive care using infant characteristics from chart review. STUDY DESIGN: For 12 hours each day, observers timed all direct care, charting, discussions, and procedures for 154 infants. Time inputs were correlated with 40 infant characteristics and resource markers, as well as the Score for Neonatal Acute Physiology (SNAP) for that day of care. RESULTS: Nurses accounted for 76%, respiratory therapists 8%, fellows 5%, nurse practitioners 7% and attendings 5% of total time invested in patient care. Nurses and respiratory therapists spent proportionately more time in direct patient care. In regression models, a limited number of variables explained 36% of the variance in time input per patient for respiratory therapists (p<0.0001), 42% for nurses (p<0.0001), and 23% for physicians and nurse practitioners (p<0.0001). CONCLUSIONS: Total labor inputs can be accurately predicted through the use of a limited number of clinical characteristics. This technique should be routinely employed to improve the accuracy of economic evaluations. Nursing accounts for the majority of time invested in neonatal care. Improved efficiency in neonatology is thus most likely to be generated by interventions that reduce direct nursing time.

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.

Intersite differences in weight growth velocity of extremely premature infants.

OBJECTIVE: To explain differences in weight growth velocity of extremely premature infants among 6 level III neonatal intensive care units (NICUs). METHODS: In 6 NICUs, we studied 564 infants, stratified by gestational age (GA), who were first admissions, survivors, <30 weeks' GA at birth, and in the NICU at least 16 days. Case mix (eg, birth weight, GA, race, illness severity, prenatal steroids), exposure to medical practices/complications (eg, respiratory support, postnatal steroids, necrotizing enterocolitis, infection), and nutritional intake (kcal/kg/d and protein in g/kg/d) were collected and used to predict weight growth velocity between day 3 and day 28 (or discharge, if transferred early) in multiple linear regression models. RESULTS: Weight growth velocities varied significantly among the 6 NICUs. Adjustment for case mix and medical factors explained little of this variability, but additional control for calorie and especially protein intake accounted for much of the intersite variability. For the average infant, adjusted growth velocity ranged from 10.4 to 14.3 g/kg/d among the sites studied. The final predictive model, including case mix and medical and nutritional factors, explained 53% of the overall variance in growth velocity. Prolonged (> or =15 days) exposure to postnatal steroids and greater severity of illness both decreased growth velocity. The model predicted that adding 1 g/kg/d protein to the mean intake for our sample would increase growth by 4.1 g/kg/d. CONCLUSIONS: Variation in nutrition explained much of the difference in growth among the NICUs studied. Mean intake of calories and protein failed to meet recommended levels, and the average growth in only 1 NICU approximated intrauterine growth standards. Increasing nutritional intake into the recommended ranges, in particular of protein, may increase growth of extremely premature infants up to or above intrauterine rates.

Association of thrombocytopenia and delivery method with intraventricular hemorrhage among very-low-birth-weight infants.

OBJECTIVES: To investigate the significance of neonatal thrombocytopenia and delivery method on the incidence of intraventricular hemorrhage in infants weighing <1500 g. STUDY DESIGN: A total of 1283 infants weighing <1500 g who were admitted to six neonatal intensive care units over 21 months were analyzed prospectively. Illness severity was measured by the Score for Neonatal Acute Physiology (SNAP). RESULTS: Of the infants analyzed, 145 (11.3%) had thrombocytopenia (platelet count <100 x 10(9)/L). The incidence of intraventricular hemorrhage was greater among infants with thrombocytopenia than among those without (44.8% vs 23.9%, P <.0001). Non-thrombocytopenic infants who were delivered vaginally had a higher incidence of intraventricular hemorrhage than those delivered via cesarean section (35.8% vs 15.9%, P <.0001). Thrombocytopenic infants who were delivered vaginally had the highest incidence of intraventricular hemorrhage (63.4% vs 37.5% for cesarean section, P =.005). Vaginal delivery and platelets < 50 x 10(9)/L on day 1 were independent risk factors for intraventricular hemorrhage (OR 2.7, 95% CI 2.0-3.8 and OR 11.2, 95% CI 3.0-42.5, respectively). CONCLUSIONS: This multicenter study confirms that thrombocytopenia and intraventricular hemorrhage are not uncommon in neonates who weigh <1500 g, and that the incidence of intraventricular hemorrhage is higher in those thrombocytopenic infants delivered vaginally.