Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Economic implications of neonatal intensive care unit collaborative quality improvement.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January 1, 1994 to December 31, 1997. Data on resources expended by hospitals to conduct this project were collected in a survey for the period January 1, 1995 to December 31, 1996. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Nine other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (N = 2993) and the 9 comparison NICUs (N = 2203); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (N = 663) and the 9 comparison NICUs (N = 1007). INTERVENTIONS: NICUs formed multidisciplinary teams which worked together to undertake a collaborative quality improvement effort between January 1995 and December 1996. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: Treatment cost per infant is the primary economic outcome measure. In addition, the resources spent by hospitals in undertaking the collaborative quality improvement effort were determined. RESULTS: Between 1994 and 1996, the median treatment cost per infant with birth weight 501 to 1500 g at the 6 project NICUs in the infection group decreased from $57 606 to $46 674 (a statistical decline); at the 4 chronic lung disease hospitals, for infants with birth weights 501 to 1000 g, it decreased from $85 959 to $77 250. Treatment costs at hospitals in the control group rose over the same period. There was heterogeneity in the effects among the NICUs in both project groups. Cost savings were maintained in the year following the intervention. On average, hospitals spent $68 206 in resources to undertake the collaborative quality improvement effort between 1995 and 1996. Two thirds of these costs were incurred in the first year, with the remaining third in the second year. The average savings per hospital in patient care costs for very low birth weight infants in the infection group was $2.3 million in the post-intervention year (1996). There was considerable heterogeneity in the cost savings across hospitals associated with participation in the collaborative quality improvement project. CONCLUSION: Cost savings may be achieved as a result of collaborative quality improvement efforts and when they occur, they appear to be sustainable, at least in the short run. In high-cost patient populations, such as infants with very low birth weights, cost savings can quickly offset institutional expenditures for quality improvement efforts.

Comparative aspects of triptans in treating migraine.

Triptans, beginning with sumatriptan, have revolutionized the treatment of migraine. New triptans in several formulations will soon become available in the United States. Although the similarities of these 5-hydroxytryptamine (5-HT) 1B/1D receptor agonists outweigh their differences, important differences in pharmacokinetics and clinical responses do exist. Subcutaneous sumatriptan has the most rapid onset of action and greatest efficacy but the most adverse effects. Intranasal sumatriptan also has rapid onset of action, but at 2 hours its efficacy is comparable to that of oral zolmitriptan. Of the oral triptans, rizatriptan seems to have the greatest early efficacy. Both rizatriptan and zolmitriptan are now available as rapidly dissolving wafers. Almotriptan, the newest of the triptans, has a response rate similar to that of oral sumatriptan and may produce fewer adverse effects. Naratriptan and frovatriptan, with their slow onset, high tolerability, and long half-lives, may have a role in aborting prolonged migraine attacks and in headache prevention. Eletriptan at higher doses (80 mg) has a response rate approaching that of rizatriptan but may be limited by potential side effects. The many triptans available offer the opportunity to individualize migraine treatment, depending on the patient's attack characteristics, tolerance, and preferences.

Comparison of three methods for recording tibial H reflex: a clinical note.

Recording the tibial H reflex from the calf is routine in clinical electromyography. Two widely used methods are Hugon's and Braddom and Johnson's. Both methods produce an H wave with an initial positive deflection. Another method, the "half and half" method, generates an H wave with an initial negative deflection. To compare these methods, H-reflex responses were recorded in the right calf of 20 normal adults with each method using identical amplifier and stimulator settings. Stimulus current was increased by increments of 0.5-1.0 mA until the H reflex and motor (M) wave responses reached maximum amplitudes (Hmax, Mmax). H wave to M wave (H/M) amplitude ratios were calculated. The half-and-half method produced greatest Hmax, Mmax, and H/M ratio. Wave form configuration for the half-and-half method was biphasic with an initial negative deflection; it was triphasic with an initial positive deflection with the other methods. The shapes of M and H waves were similar in two methods but dissimilar in one. Because of the greater amplitude and the initial negative deflection, the H wave may be easier to detect with the half-and-half method and may present a latency that is more easily determined. For these reasons, the half-and-half method is recommended for measuring amplitude and latency in clinical settings.

Population-based growth stunting.

Growth stunting, defined as height for age below the fifth percentile on a reference growth curve, is traditionally used as an indicator of nutritional status in children. Growth stunting is a population-based indicator and can indicate the prevalence of malnutrition or nutrition-related disorders among an identified population of children. Among certain segments of the U.S. child population, most notably poor children, growth stunting occurs more often than expected, suggesting that inadequate nutrition may be a problem for these children. Available general population data are not recent enough to allow for an assessment of the impact of several major public programs designed to address the risk of inadequate nutrition among children. Analysis of data from these programs does show, however, a higher-than-expected-albeit-declining level of stunting among program participants. The serious consequences of growth stunting and malnutrition-particularly impaired cognitive development-suggest that careful consideration of the growth stunting indicator should remain an important part of policy discussions on public nutrition programs.

Hospital and patient characteristics associated with variation in 28-day mortality rates for very low birth weight infants. Vermont Oxford Network.

BACKGROUND: The outcomes for very low birth weight infants vary among neonatal intensive care units (NICUs), but the reasons for this variation are not well understood. We used the database of a large neonatology research network to determine whether either admission characteristics of the infants or specific characteristics of the units such as annual patient volume and the presence of a pediatric residency program could account for observed differences in neonatal mortality rates among units. METHODS: We studied 7672 infants with birth weights from 501 to 1500 g treated during 1991 and 1992 at 62 NICUs participating in the Vermont Oxford Network Database. RESULTS: Overall, 14.7% of the study infants died within 28 days of birth (interquartile range 9.9% to 18.1%). The ratio of the number of observed deaths at an NICU to the number of deaths predicted based on the characteristics of infants treated at the NICU (standardized neonatal mortality ratio, [SNMR]) varied significantly among units (range 0 to 1.69, z = 4.24). There was no association between annual patient volume and either mortality rate (r = .17) or SNMR (r = .22). Observed mortality rates (17% vs 13%) and SNMR (1.04 vs .87) were both higher at the 24 hospitals with pediatric residency training programs than at the 38 hospitals without such programs. Hospitals with residency programs had higher average annual patient volumes (104 vs 66). In an analysis simultaneously adjusting for patient characteristics, volume, and presence of a residency program, neither volume (odds ratio [OR] per 10 additional cases treated 1.01, 95% confidence interval [CI], .98 to 1.04) nor presence of a pediatric residency program (OR 1.18, 95% CI, .94 to 1.47) was significantly associated with neonatal mortality risk. CONCLUSION: There are differences in neonatal mortality rates among NICUs that cannot be explained by differences in the measured admission characteristics of the infants, suggesting that the effectiveness of medical care varies among units. Neither the annual volume of very low birth weight infants treated in a unit nor the presence of a pediatric residency training program was independently associated with neonatal mortality rates for very low birth weight infants.

Price, public policy, and smoking in young people.

OBJECTIVE: To examine the effect of cigarette taxes, limits on public smoking, laws regulating access to tobacco by young people, and exposure to pro-tobacco and anti-tobacco messages on smoking participation and the intention to smoke among ninth-grade students (aged 13-16). DATA SOURCES: Two cross-sectional, school-based surveys (total of 15432 responses) of ninth-grade students conducted in 21 North American communities in 1990 and 1992 in conjunction with the Community Intervention Trial for Smoking Cessation. OUTCOME MEASURES: A ninth-grader was classified as a smoker if he or she reported smoking a whole cigarette on at least one of the 30 days preceding the survey. Among non-smokers, a positive intention to smoke was attributed to those who claimed they probably or definitely would be smoking within a year. RESULTS: Both smoking participation and the intent to smoke were related to differences in cigarette prices, with estimated price elasticities of -0.87 and -0.95, respectively. Boys were far more sensitive to price than girls with respect to smoking participation (elasticities of -1.51 and -0.32, respectively); however, the effect of price on the intent to smoke was similar for boys and girls. Policies limiting minors' access to tobacco (a minimum purchase age of 18 years, a ban on cigarette vending machines, and a ban on giving away free samples of tobacco products) were associated with reductions in participation and intention to smoke. Exposure to tobacco education in school was associated with decreased participation and intention to smoke. Policies that prohibited smoking in public places and in schools were not significantly related to the smoking patterns of ninth-graders. Frequency of exposure to pro-tobacco advertisements was marginally associated with increased participation and intention to smoke; paradoxically, frequency of exposure to anti-tobacco advertisements was correlated with an increased likelihood of smoking. CONCLUSIONS: Policies limiting access to tobacco by young people, increasing education about the effects of tobacco use, and a sharp and sustained increase in real cigarette excise taxes are likely to be most successful in accomplishing the US Food and Drug Administration's goal of cutting the smoking prevalence of adolescents in half over the next seven years.

Use of discount cigarettes by smokers in 20 communities in the United States, 1988-1993.

OBJECTIVE: To examine characteristics of smokers associated with the use of discount and generic cigarettes. DESIGN: Data for this analysis come from two population-based cross-sectional telephone surveys (1988 survey n = 32952; 1993 survey n = 11783) and a cohort tracking survey (n = 11966) of smokers aged 25-64 years conducted in 20 communities in the United States between 1988 and 1993 as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. OUTCOME MEASURES: In each survey, current smokers were asked to report the six-digit UPC code displayed on the side of the pack of their current cigarettes. Respondents who did not have a pack available or who could not locate the UPC code number were asked to report their usual brand of cigarettes smoked. A master list of UPC code numbers was developed so that reported UPC codes could be associated with specific cigarette brand names. Brand name cigarettes were categorised as either premium or discount brands using information from the Maxwell consumer report. Respondents who reported smoking "no name" generic cigarettes were classified as smoking a discount cigarette. RESULTS: The reported use of discount/generic cigarettes increased from 6.2% in 1988 to 23.4% in 1993. The trend toward increased use of lower priced cigarettes was evident in all 20 communities studied. The use of low priced cigarettes was associated with lower household income, higher daily cigarette consumption, and residence in an area with higher average cigarette prices. Respondents using discount/generic cigarettes were less likely to stop smoking or to reduce cigarette consumption between 1988 and 1993 compared with those using premium brand cigarettes. CONCLUSIONS: The availability of discount/generic cigarettes has made smoking more affordable, which most likely has helped the cigarette industry retain customers sensitive to price, who might have otherwise reduced consumption or stop smoking altogether.

Discrepancies in cigarette brand sales and adult market share: are new teen smokers filling the gap?

OBJECTIVE: To examine the extent and type of cigarette brand switching by adult smokers. To evaluate discrepancies between actual and projected cigarette brand sales based on changes in adult smoking patterns. DESIGN: Data analysed come from a cohort tracking survey of 11966 cigarette smokers aged 25-64 years from 20 communities in the United States who were followed between 1988 and 1993 as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. OUTCOME MEASURES: Respondents were asked about their current cigarette brand in 1988 and 1993. Brand switching was inferred when a smoker reported a different cigarette brand in 1988 and 1993. Company switching was defined as brand switching for whom a different parent company was identified for the 1993 brand compared with the brand used in 1988. A ratio measure was computed to reflect gains in market share from brand switching and losses from brand switching, quitting, and death, for specific cigarette brands, between 1988 and 1993. This ratio measure was used to estimate the projected unit sales for top-selling premium brands in 1993 and was compared with actual unit sales for the same year. RESULTS: We estimate that an average of 9.5% of smokers switched cigarettes brands and 7.6% switched companies each year. Most of those who did switch cigarette brands changed from a premium brand to a discount or generic brand. Between 1988 and 1993, top-selling premium brands such as Marlboro, Camel, and Newport, lost about four times as many adult smokers as they gained. Whereas premium brand cigarettes lost some smokers to discount and generic cigarettes, over 50% of losses were due to smokers quitting or dying. Actual unit sales were substantially higher than projected sales (based on adult market share) for Marlboro and Camel, but not for other brands. CONCLUSIONS: Most smokers are brand loyal. Price seems to be an important factor motivating brand switching among adult smokers. It appears that recruitment of new customers among the ranks of non-smokers is necessary for premium cigarette brands such as Marlboro and Camel to maintain sales comparable to previous years.