Plenary Session II: The Role of State Health Departments in Examining Care for Adverse Pregnancy Outcomes

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Plenary Session II The Role of State Health
Departments in Examining Care for Adverse
Pregnancy Outcomes

• Part one Perspectives on the history of
  regionalization and the role of neonatology and
  states in improving outcomes.
• George A. Little
• December 7, 2005

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Graven, S.N., Howe, G., and Callon, H., Perinatal
health care in Wisconsin 1967-70, In Neonatal
Intensive Care. Swyer, P. A., and Stetson, J.A.
Eds., Charles Green Publishers, 1976 (Presented
to AAP, May 1971)
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TIOP I ( 1976)

• Emphasized needs assessment and resource
  allocation
• Recommended universal risk assessment and
  organization of hospital based services
  ( levels of care)
• Major tasks ahead identified
• financing
• professional education
• initiating action

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1983
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TIOP II 1993

• Broaden focus - preconception to follow-up
  greater emphasis on outpatient care
• data, evaluation and accountability
• Existing system of care with risk assessment and
  levels of care reconfirmed

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Better care or better babies?

• 50 decrease of lt1500 g mortality in 2 cohort
  study ( 1989-90 and 1994-5)
• 1/3 decline attributed to improved condition on
  admission
• 2/3 decline attributed to NICU care
• Richardson et al, Pediatrics, 102, 1998

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Are we doing the right thing?

• Silverman, W. Is neonatal medicine in the United
  States out of step? Pediatrics. 1993 92 612-613

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Neonatal Care

• has been responsible for much of the improvement
  in perinatal outcomes
• will be able to contribute proportionately less
  to future outcome improvement
• do we have an adequate capacity?

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Pediatrics, 2001
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Neonatal Care Capacity and Need

• cross sectional analysis of 246 neonatal
  intensive care regions (NICRs)
• association between capacity (neonatologists and
  beds) and LBW and VLBW

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Neonatal Care Capacity and Need

• Regional variation not explained by need as
  expressed by LBW
• Variation across 246 NICRs greater than fourfold

High quintile 863 births/neon, 169
births/bed Low quintile 3718 births/neon, 368
births/bed
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2002
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Neonatal Care Capacity and Outcomes

• study of relationship between 3,892,208 births
  gt500 g and mortality
• risk adjusted for maternal and neonatal factors

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Neonatal Care Capacity and Outcomes

• rate lower in second NICR quintile with 4.3
  neonatologists than first with 2.7. No further
  improvement with added capacity in quintiles 3-5.
  
• no consistent relationship between number of NICU
  beds and mortality

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Is More Neonatal Intensive Care Always Better?
Insights From a Cross-National Comparison of
Reproductive Care
Thompson LA, Goodman DC and Little GA,
Pediatrics, 109, 2002
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The US compared to 3 other developed countries

• does not have consistently better birth-weight
  specific mortality
• has LBW rates that exceed other countries
• has less extensive preconception and prenatal
  services
• Expends significantly greater NICU
  resources/capita

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Theoretical Relationship of Capacity to Outcomes

Adequate
Underserved
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Pediatrics, 103,1 Jan 1999
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State perinatal QI, mandated arenas of activity

• policy development and implementation
• definition and measurement of quality
• data collection and analysis
• communication to affect change

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Survey of state MCH agencies (1998)

• few state agencies undertaking efforts in all
  four areas
• there is opportunity for states to be more
  proactive as they have legal authority and
  responsibility to assure MCH outcomes.

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Ohio

• 1977 State Perinatal Guidelines
• 6 geographically defined
• Regional Perinatal Centers
• Regional Perinatal Education
• Coordinators

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Ohio

• 2002 Perinatal Data Use Consortium
  (DUC) created
• Engage both medicine and public health
• PPOR utilized
• 6 regional teams for data-driven projects
• Create state-wide consortium
• Gradually evolve to use data for decision making
  and quality improvement

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Vermont Oxford Network
NICUs
VLBW Infants
1991 to 2004
1991 to 2004
Database now includes ¼ million records 13 of
members are international
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Database Evolution
2000 2005

• Paper Forms
• Infants lt1500 gm
• Printed Reports

• Digital Forms
• All NICU Infants
• Internet Reporting

• Electronic submissions increasing
• eNICQ Software in field
• Expanded Database increasing
• CD-ROM reporting in place
• Secure Internet reporting in 2005

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CALIORNIA PERINATAL QUALITY CARE
COLLABORATIVE(CPQCC)
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Grady Hospitals Interpregnancy Care Program A
Model Intervention in Response to the Conversion
of Data into Information
A.W. Brann, Jr., MD, Director Brian McCarthy, MD,
PI Georgia Perinatal Task Force
Anne Lang Dunlop, MD, MPH Research Fellow, WHO
Collaborating Center
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Objectives

• To review the Perinatal Periods of Risk (PPOR)
  model for identifying opportunity gaps and
  corresponding health system interventions to
  improve feto-infant mortality for a given
  location
• To demonstrate use of the PPOR model to identify
  excess feto-infant mortality and interventions
  for reducing feto-infant mortality for Georgia
• 3. To present an overview of Grady Hospitals
  Interpregnancy Care Program, a health system
  intervention for potentially decreasing recurrent
  adverse pregnancy outcomes for high-risk women.

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