RESUMO
OBJECTIVE: To evaluate impact of a multihospital collaborative quality improvement project implementing in situ simulation training for neonatal resuscitation on clinical outcomes for infants born preterm. STUDY DESIGN: Twelve neonatal intensive care units were divided into 4 cohorts; each completed a 15-month long program in a stepped wedge manner. Data from California Perinatal Quality Care Collaborative were used to evaluate clinical outcomes. Infants with very low birth weight between 22 through 31 weeks gestation were included. Primary outcome was survival without chronic lung disease (CLD); secondary outcomes included intubation in the delivery room, delivery room continuous positive airway pressure, hypothermia (<36°C) upon neonatal intensive care unit admission, severe intraventricular hemorrhage, and mortality before hospital discharge. A mixed effects multivariable regression model was used to assess the intervention effect. RESULTS: Between March 2017 and December 2020, a total of 2626 eligible very low birth weight births occurred at 12 collaborative participating sites. Rate of survival without CLD at participating sites was 74.1% in March to August 2017 and 76.0% in July to December 2020 (risk ratio 1.03; [0.94-1.12]); no significant improvement occurred during the study period for both participating and nonparticipating sites. The effect of in situ simulation on all secondary outcomes was stable. CONCLUSIONS: Implementation of a multihospital collaborative providing in situ training for neonatal resuscitation did not result in significant improvement in survival without CLD. Ongoing in situ simulations may have an impact on unit practice and unmeasured outcomes.
Assuntos
Pneumopatias , Ressuscitação , Gravidez , Feminino , Recém-Nascido , Humanos , Lactente , Recém-Nascido de muito Baixo Peso , Idade Gestacional , Pressão Positiva Contínua nas Vias Aéreas , Unidades de Terapia Intensiva NeonatalRESUMO
OBJECTIVE: To determine whether outcomes among infants with very low birth weight (VLBW) vary according to the birthplace (Japan or California) controlling for maternal ethnicity. STUDY DESIGN: Severe intraventricular hemorrhage (IVH) and mortality were ascertained for infants with VLBW born at 24-29 weeks of gestation during 2008-2017 and retrospectively analyzed by the country of birth for mothers and infants (Japan or California). RESULTS: Rates of severe IVH, mortality, or combined IVH/mortality were lower in the 24 095 infants born in Japan (5.1%, 5.0%, 8.8% respectively) compared with infants born in California either to 157 mothers with Japanese ethnicity (12.5%, 9.7%, 17.8%) or to a comparison group of 6173 non-Hispanic white mothers (8.4%, 8.8%, 14.6%). ORs for adverse outcomes were increased for infants born in California to mothers with Japanese ethnicity compared with infants born in Japan for severe IVH (OR, 3.31; 95% CI, 1.93-5.68), mortality (3.73; 95% CI, 2.03-6.86), and the combined outcome (3.26; 95% CI, 2.02-5.27). The odds of these outcomes also were increased for infants born in California to non-Hispanic white mothers compared with infants born in Japan. Outcomes of infants born in California did not differ by Japanese or non-Hispanic white maternal ethnicity. CONCLUSIONS: Low rates of severe IVH and mortality for infants with VLBW born in Japan were not seen in infants born in California to mothers with Japanese ethnicity. Differences in systems of regional perinatal care, social environment, and the quality of perinatal care may partially account for these differences in outcomes.
Assuntos
Entorno do Parto , Hemorragia Cerebral Intraventricular/epidemiologia , Mortalidade Infantil , Recém-Nascido de muito Baixo Peso , Adolescente , Adulto , Índice de Apgar , Povo Asiático , California/epidemiologia , Cesárea/estatística & dados numéricos , Corioamnionite/epidemiologia , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Feminino , Idade Gestacional , Glucocorticoides/uso terapêutico , Humanos , Hipertensão/epidemiologia , Lactente , Recém-Nascido , Japão/epidemiologia , Idade Materna , Prole de Múltiplos Nascimentos/estatística & dados numéricos , Obesidade Materna , Gravidez , Complicações na Gravidez/epidemiologia , Estudos Retrospectivos , População Branca , Adulto JovemRESUMO
OBJECTIVE: To examine the hypothesis that increasing rates and differential uptake of antenatal steroids would bias estimation of impact of antenatal steroids on neonatal death and severe (grade III-IV) intraventricular hemorrhage (IVH). STUDY DESIGN: The study population included infants born between 24 and 28 weeks of gestational age in the California Perinatal Quality Care Collaborative. Outcomes were in-hospital mortality and severe IVH. Mixed multivariable logistic regression models estimated the effect of antenatal steroid exposure, one model accounting for individual risk factors as fixed effects, and a second model incorporating a predicted probability factor estimating overall risk status for each time period. RESULTS: The study cohort included 28 252 infants. Antenatal steroid exposure increased from 80.1% in 2005 to 90.3% in 2016, severe IVH decreased from 14.5% to 9.0%, and mortality decreased from 12.8% to 9.1%. When stratified by group, 3-year observed outcomes improved significantly in infants exposed to antenatal steroids (12.5%-8.6% for IVH, 11.5%-8.8% for death) but not in those not exposed (20.7%-19.1% and 16.6%-15.5%, respectively). Women not receiving antenatal steroids had greater risk profile (such as no prenatal care) and greater predicted probability for severe IVH and mortality. Both outcomes exhibited little change (P > .05) over time for the group without antenatal steroids. In contrast, in women receiving antenatal steroids, observed and adjusted rates for both outcomes decreased (P < .0001). CONCLUSIONS: As the population's proportion of antenatal steroid use increased, the observed positive effect of antenatal steroids also increased. This apparent increase may be designated as the "population improvement bias."
Assuntos
Hemorragia Cerebral Intraventricular/epidemiologia , Glucocorticoides/uso terapêutico , Mortalidade Infantil , Recém-Nascido Prematuro , Cuidado Pré-Natal , Adulto , California/epidemiologia , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Doenças do Prematuro/epidemiologia , Recém-Nascido de muito Baixo Peso , Unidades de Terapia Intensiva Neonatal , Masculino , Gravidez , Nascimento Prematuro , Adulto JovemRESUMO
OBJECTIVE: To examine changes in referral rates of very low birthweight (birthweight <1500 g) infants to high-risk infant follow-up in California and identify factors associated with referral before and after implementation of a statewide initiative in 2013 to address disparities in referral. STUDY DESIGN: We included very low birthweight infants born 2010-2016 in the population-based California Perinatal Quality Care Collaborative who survived to discharge home. We used multivariable logistic regression to examine factors associated with referral and derive risk-adjusted referral rates by neonatal intensive care unit (NICU) and region. RESULTS: Referral rate improved from 83.0% (preinitiative period) to 94.9% (postinitiative period); yielding an OR of 1.48 (95% CI, 1.26-1.72) for referral in the postinitiative period after adjustment for year. Referral rates improved the most (≥15%) for infants born at ≥33 weeks of gestation, with a birthweight of 1251-1500 g, and born in intermediate and lower volume NICUs. After the initiative, Hispanic ethnicity, small for gestational age status, congenital anomalies, and major morbidities were no longer associated with a decreased odds of referral. Lower birthweight, outborn status, and higher NICU volume were no longer associated with increased odds of referral. African American race was associated with lower odds of referral, and higher NICU level with a higher odds of referral during both time periods. Referral improved in many previously poor-performing NICUs and regions. CONCLUSIONS: High-risk infant follow-up referral of very low birthweight infants improved substantially across all sociodemographic, perinatal, and clinical variables after the statewide initiative, although disparities remain. Our results demonstrate the benefit of a targeted initiative in California, which may be applicable to other quality collaboratives.
Assuntos
Assistência ao Convalescente , Encaminhamento e Consulta/estatística & dados numéricos , California , Feminino , Disparidades em Assistência à Saúde , Humanos , Recém-Nascido , Recém-Nascido de muito Baixo Peso , Masculino , Medição de RiscoRESUMO
OBJECTIVES: To determine rates of at least 1 high-risk infant follow-up (HRIF) visit by 12 months corrected age, and factors associated with successful first visit among very low birth weight (VLBW) infants in a statewide population-based setting. STUDY DESIGN: We used the linked California Perinatal Quality of Care Collaborative and California Perinatal Quality of Care Collaborative-California Children's Services HRIF databases. Multivariable logistic regression examined independent associations of maternal, sociodemographic, neonatal clinical, and HRIF program factors with a successful first HRIF visit among VLBW infants born in 2010-2011. RESULTS: Among 6512 VLBW children referred to HRIF, 4938 (76%) attended a first visit. Higher odds for first HRIF visit attendance was associated with older maternal age (OR, 1.48; 95% CI, 1.27-1.72; 30-39 vs 20-29 years), lower birth weight (OR, 2.11; 95% CI, 1.69-2.65; ≤750 g vs 1251-1499 g), private insurance (OR, 1.65; 95% CI, 1.19-2.31), a history of severe intracranial hemorrhage (OR, 1.61; 95% CI, 1.12-2.30), 2 parents as primary caregivers (OR, 1.18, 95% CI 1.03-1.36), and higher HRIF program volume (OR, 2.62; 95% CI, 1.88-3.66; second vs lowest quartile); and lower odds with maternal race African American or black (OR, 0.65; 95% CI, 0.54-0.78), and greater distance to HRIF program (OR, 0.69; 95% CI, 0.57-0.83). Rates varied substantially across HRIF programs, which remained after risk adjustment. CONCLUSIONS: In a population-based California VLBW cohort, maternal, sociodemographic, and home- and program-level disparities were associated with HRIF non-attendance. These findings underscore the need to identify challenges in access and resource risk factors during hospitalization in the neonatal intensive care unit, provide enhanced education about the benefits of HRIF, and create comprehensive neonatal intensive care unit-to-home transition approaches.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Serviços de Saúde da Criança/estatística & dados numéricos , Recém-Nascido de muito Baixo Peso , California , Feminino , Seguimentos , Humanos , Lactente , Masculino , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Medição de Risco , Fatores de RiscoRESUMO
OBJECTIVE: To test the hypothesis that neonatal intensive care unit (NICU)-specific changes in patent ductus arteriosus (PDA) management are associated with changes in local outcomes in preterm infants. STUDY DESIGN: This retrospective repeated-measures study of aggregated data included infants born 400-1499 g admitted within 2 days of delivery to NICUs participating in the California Perinatal Quality Care Collaborative. The period 2008-2015 was divided into four 2-year epochs. For each epoch and NICU, we calculated proportions of infants receiving cyclooxygenase inhibitor (COXI) or PDA ligation and determined NICU-specific changes in these therapies between consecutive epochs. Generalized estimating equations were used to examine adjusted relationships between NICU-specific changes in PDA management and contemporaneous changes in local outcomes. RESULTS: We included 642 observations of interepoch change at 119 hospitals summarizing 32 094 infants. NICU-specific changes in COXI use and ligation showed significant dose-response associations with contemporaneous changes in adjusted local outcomes. Each percentage point decrease in NICU-specific proportion treated with either COXI or ligation was associated with a 0.21 percentage point contemporaneous increase in adjusted local in-hospital mortality (95% CI 0.06, 0.33; P = .005) among infants born 400-749 g. In contrast, decreasing NICU-specific ligation rate among infants 1000-1499 g was associated with decreasing adjusted local bronchopulmonary dysplasia (P = .009) and death or bronchopulmonary dysplasia (P = .01). CONCLUSIONS: NICU-specific outcomes of preterm birth co-vary with local PDA management. Treatment for PDA closure may benefit some infants born 400-749 g. Decreasing NICU-specific rates of COXI use or ligation were not associated with increases in local adjusted rates of examined adverse outcomes in larger preterm infants.
Assuntos
Displasia Broncopulmonar/mortalidade , Permeabilidade do Canal Arterial/mortalidade , Permeabilidade do Canal Arterial/terapia , Mortalidade Hospitalar , Unidades de Terapia Intensiva Neonatal/organização & administração , Nascimento Prematuro , Displasia Broncopulmonar/diagnóstico por imagem , Displasia Broncopulmonar/terapia , California , Causas de Morte , Estudos de Coortes , Inibidores de Ciclo-Oxigenase/uso terapêutico , Permeabilidade do Canal Arterial/diagnóstico por imagem , Feminino , Humanos , Recém-Nascido , Ligadura/métodos , Masculino , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Gravidez , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: To determine if temperature regulation is improved during neonatal transport using a servo-regulated cooling device when compared with standard practice. STUDY DESIGN: We performed a multicenter, randomized, nonmasked clinical trial in newborns with neonatal encephalopathy cooled during transport to 9 neonatal intensive care units in California. Newborns who met institutional criteria for therapeutic hypothermia were randomly assigned to receive cooling according to usual center practices vs device servo-regulated cooling. The primary outcome was the percentage of temperatures in target range (33°-34°C) during transport. Secondary outcomes included percentage of newborns reaching target temperature any time during transport, time to target temperature, and percentage of newborns in target range 1 hour after cooling initiation. RESULTS: One hundred newborns were enrolled: 49 to control arm and 51 to device arm. Baseline demographics did not differ with the exception of cord pH. For each subject, the percentage of temperatures in the target range was calculated. Infants cooled using the device had a higher percentage of temperatures in target range compared with control infants (median 73% [IQR 17-88] vs 0% [IQR 0-52], P < .001). More subjects reached target temperature during transport using the servo-regulated device (80% vs 49%, P <.001), and in a shorter time period (44 ± 31 minutes vs 63 ± 37 minutes, P = .04). Device-cooled infants reached target temperature by 1 hour with greater frequency than control infants (71% vs 20%, P < .001). CONCLUSIONS: Cooling using a servo-regulated device provides more predictable temperature management during neonatal transport than does usual care for outborn newborns with neonatal encephalopathy.
Assuntos
Asfixia Neonatal/complicações , Temperatura Corporal/fisiologia , Encefalopatias/terapia , Hipotermia Induzida/métodos , Doenças do Recém-Nascido/terapia , Unidades de Terapia Intensiva Neonatal , Transporte de Pacientes/métodos , Asfixia Neonatal/terapia , Encefalopatias/etiologia , Feminino , Seguimentos , Humanos , Recém-Nascido , Masculino , PrognósticoRESUMO
OBJECTIVES: To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative. STUDY DESIGN: Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral. RESULTS: In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ≤ 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment. CONCLUSIONS: There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.