Video-call based newborn triage system for local birth centres can be established without major instalment costs using commercially available smartphones.

Neonates often develop transition problems after low-risk birth, precise assessment of which is difficult at primary birth centres. The aim of this study was to assess whether a video triage system can be established without a specially designed communication system between local birth centres and a tertiary neonatal intensive care unit in a region with a population of 700,000. 761 neonates who were referred to a tertiary neonatal intensive care unit were examined. During period 1 (April 2011-August 2015), only a voice call was available for consultations, whereas, during period 2 (September 2015-December 2017), a video call was additionally available. The respiratory condition was assessed based on an established visual assessment tool. A video consultation system was established by connecting personal smartphones at local birth centres with a host computer at a tertiary neonatal intensive care centre. During period 2, video-based triage was performed for 42.4% of 236 consultations at 30 birth centres. Sensitivity and specificity for predicting newborns with critical respiratory dysfunction changed from 0.758 to 0.898 and 0.684 to 0.661, respectively. A video consultation system for ill neonates was established without major instalment costs. Our strategy might improve the transportation system in both high- and low-resource settings.

Neonatologist salary: factors, equity and gender.

OBJECTIVE: Physician compensation has been found to be influenced by gender, academic affiliation, specialty, productivity, and time in practice. This study explores their impact in the field of neonatology to inform institutional strategic planning and decisions by current and future practitioners. STUDY DESIGN: A voluntary anonymous survey was distributed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine with a 15% response rate. The survey contained questions assessing clinician characteristics, work environment, and professional productivity. Statistical analysis was done using JMP Pro 14.0.0 by SAS. RESULTS: Median salary was $256,000 (interquartile range, $213,608-315,000). Generalized linear model found that years post fellowship, academic affiliation, gender, practice location, professional duties, and clinical team member types independently influenced expected salary. CONCLUSION: Several factors influence the expected compensation of this cohort of neonatologists, even after adjustments for differences in clinician characteristics, work environment, and productivity.

Improving Value in Neonatal Intensive Care.

Work within the US health care system has sought to improve outcomes, decrease costs, and improve the patient experience. Combining those three elements leads to value-added care. Quality improvement within neonatology has focused primarily on the improvement of clinical outcomes without explicit consideration of cost. Future improvement efforts in neonatology should consider opportunities to decrease or eliminate waste, and improve outcomes. Consideration of how a change affects all stakeholders reveals potential cost-saving opportunities, and developing aims with value in mind facilitates understanding and goal-setting with senior administrative leaders.

Interdisciplinary onsite team-based simulation training in the neonatal intensive care unit: a pilot report.

OBJECTIVE: Simulation training improves individual clinician confidence, performance and self-efficacy in resuscitation and procedural training experiences. The reality of resuscitation experiences in the neonatal intensive care unit (NICU) is that they are team-accomplished events. However, limited data exist on team-based simulation training (TBST) in the NICU. We report the experience of TBST over a 4-year period. STUDY DESIGN: This is a retrospective report of 65 TBST events in a 71-bed Level IV NICU at a regional subspecialty children's hospital. Participants were more than 500 NICU staff, including neonatal/cardiac/surgical attendings, neonatal fellows, neonatal nurse practitioners, pediatric residents, registered nurses and respiratory therapists. Background work, common case scenarios, training objectives and learning opportunities were reported, along with discipline-specific, and team and system areas for improvement. Qualitative, subjective data were tracked and efforts at collecting quantitative, objective data are ongoing. RESULTS: Seventy-five TBST events were scheduled from November 2010 through December 2014; 10 of these were canceled. TBST events occurred both night (n=23) and day (n=42), and also on weekends (n=19), using high-fidelity (n=42) and low-fidelity (n=23) systems. Resuscitation team participants at each TBST were 12-30 providers and staff. The duration of each TBST event was 30-65 min including debriefing. Systems issues were identified and corrected, including problems activating the code pathway, issues using a pager activation system and confusion over resuscitation team roles and responsibilities. Educational needs were addressed, focused on topic areas that included arrhythmias and use of extracorporeal cardiopulmonary resuscitation. CONCLUSION: With appropriate planning and implementation, TBST is feasible and realistic in a busy NICU.

Costo efectividad y análisis de impacto presupuestario del óxido nítrico inhalatorio neonatal en un hospital, desde la perspectiva del sistema público de salud / Cost effectiveness and budget impact analysis of inhaled nitric oxide in a neonatal unit from the perspective of the public health system

El óxido nítrico inhalatorio (ONi) es actualmente la terapia de primera línea en la insuficiencia respiratoria hipoxémica grave del recién nacido; la mayor parte de los centros neonatales de regiones en Chile no cuentan con esta alternativa terapéutica. Objetivo: Determinar el costo-efectividad del ONi en el tratamiento de la insuficiencia respiratoria asociada a hipertensión pulmonar del recién nacido, comparado con el cuidado habitual y el traslado a un centro de mayor complejidad. Pacientes y método: Se modeló un árbol de decisiones clínicas desde la perspectiva del sistema de salud público chileno, se calcularon razones de costo-efectividad incremental (ICER), se realizó análisis de sensibilidad determinístico y probabilístico, se estimó el impacto presupuestario, software: TreeAge Health Care Pro 2014. Resultados: La alternativa ONi produce un aumento promedio en los costos de 11,7 millones de pesos por paciente tratado, con una razón de costo-efectividad incremental comparado con el cuidado habitual de 23 millones de pesos por muerte o caso de oxigenación extracorpórea evitada. Al sensibilizar los resultados por incidencia, encontramos que a partir de 7 casos tratados al año resulta menos costoso el óxido nítrico que el traslado a un centro de mayor complejidad. Conclusiones: Desde la perspectiva de un hospital regional chileno incorporar ONi en el manejo de la insuficiencia respiratoria neonatal resulta la alternativa óptima en la mayoría de los escenarios posibles.

Inhaled nitric oxide (iNO) is currently the first-line therapy in severe hypoxaemic respiratory failure of the newborn. Most of regional neonatal centres in Chile do not have this therapeutic alternative. Objective: To determine the cost effectiveness of inhaled nitric oxide in the treatment of respiratory failure associated with pulmonary hypertension of the newborn compared to the usual care, including the transfer to a more complex unit. Patients and method: A clinical decision tree was designed from the perspective of Chilean Public Health Service. Incremental cost effectiveness rates (ICER) were calculated, deterministic sensitivity analysis was performed, and probabilistic budget impact was estimated using: TreeAge Pro Healthcare 2014 software. Results: The iNO option leads to an increase in mean cost of $ 11.7 million Chilean pesos (€ 15,000) per patient treated, with an ICER compared with the usual care of $ 23 million pesos (€ 30,000) in case of death or ECMO avoided. By sensitising the results by incidence, it was found that from 7 cases and upwards treated annually, inhaled nitric oxide is less costly than the transfer to a more complex unit. Conclusions: From the perspective of a Chilean regional hospital, incorporating inhaled nitric oxide into the management of neonatal respiratory failure is the optimal alternative in most scenarios.

Cost-effective and low-technology options for simulation and training in neonatology.

The purpose of this review is to explore low-cost options for simulation and training in neonatology. Numerous cost-effective options exist for simulation and training in neonatology. Lower cost options are available for teaching clinical skills and procedural training in neonatal intubation, chest tube insertion, and pericardiocentesis, among others. Cost-effective, low-cost options for simulation-based education can be developed and shared in order to optimize the neonatal simulation training experience.

[Cost effectiveness and budget impact analysis of inhaled nitric oxide in a neonatal unit from the perspective of the public health system]. / Costo efectividad y análisis de impacto presupuestario del óxido nítrico inhalatorio neonatal en un hospital, desde la perspectiva del sistema público de salud.

Inhaled nitric oxide (iNO) is currently the first-line therapy in severe hypoxaemic respiratory failure of the newborn. Most of regional neonatal centres in Chile do not have this therapeutic alternative. OBJECTIVE: To determine the cost effectiveness of inhaled nitric oxide in the treatment of respiratory failure associated with pulmonary hypertension of the newborn compared to the usual care, including the transfer to a more complex unit. PATIENTS AND METHOD: A clinical decision tree was designed from the perspective of Chilean Public Health Service. Incremental cost effectiveness rates (ICER) were calculated, deterministic sensitivity analysis was performed, and probabilistic budget impact was estimated using: TreeAge Pro Healthcare 2014 software. RESULTS: The iNO option leads to an increase in mean cost of $ 11.7 million Chilean pesos (€15,000) per patient treated, with an ICER compared with the usual care of $23 million pesos (€30,000) in case of death or ECMO avoided. By sensitising the results by incidence, it was found that from 7 cases and upwards treated annually, inhaled nitric oxide is less costly than the transfer to a more complex unit. CONCLUSIONS: From the perspective of a Chilean regional hospital, incorporating inhaled nitric oxide into the management of neonatal respiratory failure is the optimal alternative in most scenarios.

Evidence, Quality, and Waste: Solving the Value Equation in Neonatology.

Rising health care costs challenge governments, payers, and providers in delivering health care services. Tremendous pressures result to deliver better quality care while simultaneously reducing costs. This has led to a wholesale re-examination of current practice methods, including explicit consideration of efficiency and waste. Traditionally, reductions in the costs of care have been considered as independent, and sometimes even antithetical, to the practice of high-quality, intensive medicine. However, it is evident that provision of evidence-based, locally relevant care can result in improved outcomes, lower resource utilization, and opportunities to reallocate resources. This is particularly relevant to the practice of neonatology. In the United States, 12% of the annual birth cohort is affected by preterm birth, and 3% is affected by congenital anomalies. Both of these conditions are associated with costly health care during, and often long after, the NICU admission. We will discuss how 3 drivers of clinical practice in neonatal care (evidence-based medicine, evidence-based economics, and quality improvement) can together optimize clinical and fiscal outcomes.

What explains DRG upcoding in neonatology? The roles of financial incentives and infant health.

We use the introduction of diagnosis related groups (DRGs) in German neonatology to study the determinants of upcoding. Since 2003, reimbursement is based inter alia on birth weight, with substantial discontinuities at eight thresholds. These discontinuities create incentives to upcode preterm infants into classes of lower birth weight. Using data from the German birth statistics 1996-2010 and German hospital data from 2006 to 2011, we show that (1) since the introduction of DRGs, hospitals have upcoded at least 12,000 preterm infants and gained additional reimbursement in excess of 100 million Euro; (2) upcoding rates are systematically higher at thresholds with larger reimbursement hikes and in hospitals that subsequently treat preterm infants, i.e. where the gains accrue; (3) upcoding is systematically linked with newborn health conditional on birth weight. Doctors and midwives respond to financial incentives by not upcoding newborns with low survival probabilities, and by upcoding infants with higher expected treatment costs.

Collaboration, not competition: cost analysis of neonatal nurse practitioner plus neonatologist versus neonatologist-only care models.

BACKGROUND: Although advanced practice in neonatal nursing is accepted and supported by the American Academy of Pediatrics and National Association of Neonatal Nurse Practitioners, less than one-half of all states allow independent prescriptive authority by advanced practice nurse practitioners. PURPOSE: The purpose of this study was to compare costs of a collaborative practice model that includes neonatal nurse practitioner (NNP) plus neonatologist (Neo) versus a neonatologist only (Neo-Only) practice in Washington state. Published Internet median salary figures from 3 sources were averaged to produce mean ± SD provider salaries, and costs for each care model were calculated in this descriptive, comparative study. FINDINGS/RESULTS: Median NNP versus Neo salaries were $99,773 ± $5206 versus $228,871 ± $9654, respectively (P < .0001). The NNP + Neo (5 NNP/3 Neo full-time equivalents [FTEs]) cost $1,185,475 versus Neo-Only (8 Neo FTEs) cost $1,830,960. The NNP + Neo practice model with 8 FTEs suggests a cost savings, with assumed equivalent reimbursement, of $645,485/year. IMPLICATIONS FOR PRACTICE: These results may provide the impetus for more states to adopt broader scope of practice licensure for NNPs. IMPLICATIONS FOR RESEARCH: These data may provide rationale for analysis of actual costs and outcomes of collaborative practice.

Costo de atención de los recién nacidos en un hospital público general interzonal de la Provincia de Buenos Aires / Cost of Care of Newborns in a Public Regional General Hospital in the Province of Buenos Aires

Algunos pacientes de los servicios de Neonatología requieren una gran cantidad de prestaciones de alta complejidad. Sin embargo, existe muy poca información sobre los costos que eso implica. OBJETIVO: Estimar el costo total y por área del Servicio de Neonatología del Hospital Penna de BahíaBlanca, así como el costo unitario por recién nacido (RN) sano y por día de internación de aquellos pacientes hospitalizados. MÉTODOS: Se incluyó a los RN vivos atendidos en Neonatología del Hospital Penna en 2011, dentro de dos categorías: los recién nacidos a término sanos (RNTS) y los que requirieron internación (RNI). Se describió la estructura del servicio y el proceso de atención, se recogieron datos de costos directos, se asignaron costos por área y se estimó el costo unitario de RNTS y por día de internación. RESULTADOS: En 2011, el costo directo anual del servicio fue de $8.835.407 (US$2.118.803). El costo unitario por cada RNTS fue de $566 (US$136) por parto natural y de $604 (US$145) por cesárea. Dentro de estos costos, el de mayor incidencia (70%) fue el salarial. El costo por día de internación de un RNI fue de $1.028 (US$247). El 69% de ese valor correspondió a los salarios y el 23%, a insumos. CONCLUSIONES: El costo de mayor impacto es el salarial y el área de mayor incidencia es la de internación, dada la complejidad de la atención de los RN de riesgo...

Some patients in neonatal units require many high-complexity procedures. How ever, there is very little information about the costs. OBJECTIVE:To estimate the total cost and the cost by area of the Neonatology Unit of the Penna Hospital in Bahía Blanca; as well as the unit cost per healthy newborn baby and perday of hospitalization for those referred to the inpatient area. METHODS: All live newborns (NB) assisted at the Neonatology Unit of the Penna Hospital in 2011 were included and divided in two groups: healthy term newborns(HTNB) and newborns requiring admission (NBA).The study included description of the unit structure and process of care, collection of direct costs, cost allocation by area, estimation of unit cost for HTNB and per day of hospitalization. RESULTS: In 2011, the direct annual cost of the unit was $8,835,407 (US$2,118,803). The unit cost per HTNB was $566 (US$136) with natural birth and $604 (US$145) with cesarean section. Wage costs had the highest relative weight (70%). The cost per day of NBA hospitalization was $1,028 (US$247). Wage costs totaled 69% of this value, while inputs represented 23%. CONCLUSIONS: The cost of greater impact is the wage and the area of higest incidence is the placement, given the complexity of the newborns care at risk...

Análisis económico de la promoción intensiva y especializada de la lactancia materna en las unidades neonatales en España / Economic analysis of specialised and intensive promotion of breastfeeding in neonatal units in Spain

Introducción: A pesar de que la lactancia materna (LM) es el alimento idóneo para el neonato porque cubre sus necesidades de crecimiento y le proporciona inmunidad activa frente a diversas enfermedades; esta es sustituida frecuentemente por la lactancia artificial. Se estimó el coste-efectividad de una mayor promoción de la LM en las unidades neonatales mediante la intervención intensiva y especializada de enfermeras o matronas dedicadas a ese propósito. Métodos: Se hizo un análisis de coste-efectividad, mediante un modelo de análisis de decisiones en el que se incluyeron los datos disponibles sobre una intervención especializada para la promoción de la LM, su efectividad, las consecuencias a corto plazo (sepsis, enterocolitis necrosante) y largo plazo (discapacidad por daño neurológico) de las diferentes formas de lactancia, así como la mortalidad, los costes y las utilidades que conllevan, obtenidos de la literatura médica y de los estudios y fuentes españolas disponibles. El análisis se limitó a 3 subgrupos de neonatos de bajo peso (500-999g, 1.000-1.749g y 1.750-2.500g). Resultados: En el análisis determinístico la intervención fue «dominante» para los 3 subgrupos de neonatos, lo que significa que fue más eficaz, con menores costes, que la no intervención. Los análisis probabilísticos de Monte Carlo confirmaron la estabilidad del resultado, con probabilidades de dominancia del 100, el 100 y el 99,9% para los 3 subgrupos de pesos, respectivamente. La intervención dejaría de ser coste-efectiva con costes de la intervención por puérpera de 70.504 €, 14.742 € y 7.106 €, respectivamente. Estos costes estarían muy por encima del máximo estimado (12,51 €). Conclusiones: Según el presente modelo, la promoción de la lactancia materna mediante una intervención intensiva y especializada de enfermeras o matronas dedicadas a ese propósito puede ser coste-efectiva en el caso de las puérperas con neonatos de bajo peso (500-2.500g)(AU)

Introduction: Although breastfeeding (BF) is the ideal food for newborns because it covers their growing needs and provides active immunity against various diseases, it is often replaced by artificial feeding. We estimated the cost-effectiveness of increased promotion of BF in neonatal units with intensive intervention with specialised nurses or midwives dedicated to this purpose. Methods: An analysis of cost-effectiveness, using a decision analysis model which included data on a specialised intervention for the promotion of BF, its effectiveness in the short-term (sepsis, necrotizing enterocolitis) and long-term (disabled due to neurodevelopmental impairment) of the different types of milk consumed, as well as the mortality, costs and benefits of these. Data was also obtained from current medical literature, studies and Spanish sources. The analysis was limited to three subgroups of low birthweights (500-999g, 1000-1749g, 1750-2500g). Results: In the deterministic analysis, the intervention was "dominant" for the three subgroups of infants, which meant it was more effective and with lower costs, than no intervention. The Monte Carlo probabilistic analysis confirmed the robustness of the result with probabilities of dominance of 100%, 100% and 99.9% for the three subgroups of weights, respectively. The intervention would be cost-effective with costs of puerperal intervention of € 70,504, € 14,742 and € 7,106, respectively. These costs would be well above the estimated maximum (€ 12.51). Conclusions: According to this model, the promotion of breastfeeding through an intensive promotion and with specialised nurses or midwives dedicated to this purpose, may be cost-effective in the case of puerperal women with low birth weight neonates (500-2500g)(AU)

Early neonatal special care units and their scientific achievements.

Treatment of sick neonates originated in maternity and foundling hospitals in the 19th century. Nosocomial infections and difficult logistics of wet-nursing prevented admission of neonates in most children's hospitals well into the 20th century. In this article, 31 hospitals are described, all located in large cities, in which preterm and sick neonates were treated before the Great Depression. Even though mostly initiated by private charity, these institutions performed research right from the start. Topics included warming and feeding preterm infants, collecting and distributing human milk, developing and storing breast milk substitutes, prevention of rickets and nosocomial infections, maternal and public education regarding infection control, pathoanatomic characterisation of diseases and malformations and epidemiologic studies of infant mortality. These pioneering hospitals, their founding dates, researchers and classic publications are presented in a table.

Neonatology in the emerging countries: the strategies and health-economics challenges related to prevention of neonatal and infant infections.

The prevalence of neonatal and infant infections is higher in emerging countries when compared to the developed world. Major factors associated to this increased frequency include the scarcity of trained health personnel, overcrowding of the neonatal units, late onset and slow advance of feeding, use of formula instead of breastfeeding, failure to comply with handwashing recommendations, and excessive use of antibiotics, resulting in the emergence of resistant strains. Infants discharged home frequently share rooms with a large number of siblings and other cohabitants, increasing the risk of infection by respiratory viruses. Several strategies are described that could decrease these serious problems which impact increasing significantly neonatal and infant mortality rates in developing countries.

Drug policy in Europe Research and funding in neonates: current challenges, future perspectives, new opportunities.

The availability of drugs for neonates is limited as evaluation is said more difficult in neonates than in older patients and adults, resulting in off-label drug use. Indeed, diseases may be specific to the neonatal period, the impact of immaturity and rapid developmental changes in the first days/weeks of life is important, and drugs may have short and long-term effects including developmental toxicity. To improve such situation, both the US and the EU have introduce paediatric legislation and the EMA has issued guidelines to optimize drug evaluation in paediatric populations including neonates. In addition, the following collaborative projects were funded by the EU in the co-operative programme of FP7. As preterm and term neonates are prone to infections which result in increase morbidity and mortality, the TINN (Treat Infections in Neonates) and TINN2 projects aim to evaluate off-patent anti-infectious drugs included in the EMEA priority list, ciprofloxacin/fluconazole and azithromycin respectively in the two projects. The final aim is to obtain a Paediatric Use Marketing Authorization for these drugs in neonates. In addition, TINN will build up a network of units with experience in evaluating anti-infective agents in neonates. An additional important initiative called GRIP (Global Research in Paediatrics) will focus on paediatric clinical pharmacology training and will facilitate the development and safe use of medicine in children.

Pay for performance in neonatal-perinatal medicine--will the quality of health care improve in the neonatal intensive care unit? A business model for improving outcomes in the neonatal intensive care unit.

Because neonatal medicine is such an expensive contributor to health care in the United States--with a small population of infants accounting for very high health care costs--there has been a fair amount of attention given to this group of patients. An idea that has received increasing attention in this discussion is pay for performance. This article discusses the concept of pay for performance, examines what potential benefits and risks exist in this model, and investigates how it might achieve the desired goals if implemented in a thoughtful way.

The corporate transformation of medical specialty care: the exemplary case of neonatology.

The key to wealth in health care is the physician, who certifies to third-party payers that health care items and services are necessary for patient care. To compete more effectively for this wealth, physician specialists are organizing their practices into for-profit corporations and employing other physicians. Focusing on neonatology, this article describes the prevailing business model of these for-profit medical groups as controlling employed physicians through restrictive employment contract provisions, e.g., non-compete and mandatory arbitration clauses. With this business model and because of deficiencies in current law, for-profit medical groups eliminate competition from other physician specialists to the detriment of patients and consumers.