ANGELS: Does it Work?

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ANGELS Does it Work?

• Whit Hall MD

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ANGELS

• Education
• Guidelines
• Referral
• Arkansas, a rural state
• 3 areas with practicing neonatologists
• Other areas with pediatricians

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ANGELS Education

• Monthly teleconference meetings
• Face to face interaction
• Two way street
• AHEC contribution

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ANGELS Guidelines

• Buy-in to guidelines
• Apnea
• Pain
• Hyperbilirubinemia, etc
• Published in AMJ
• Contribution of practicing physicians (e.g.,
  recommendation on apnea)
• Evidenced based

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ANGELS Regionalization

• Better communication
• Town gown gap narrowed
• More appropriate (not necessarily more) referrals
• Is it a good thing for the preterm neonate??

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Regionalization History

• Improved outcomes in Wisconsin (Graven, 1977)
• Improved outcomes in Canada (Sankaran K, 2002)
• Improved rates of IVH Canada (Synnes a, 2002)
• Improved outcomes in AR (Kirby, 1995, Palmer,
  Hall RW, 2005)

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Maternal referral

• Numerous articles attesting to that
• Improved outcomes in IVH in California (Towers C,
  2000) and Kansas (Hall Robert, 2003)
• Improved mortality outcomes in perinatal Canadian
  centers compared to free standing childrens
  hospitals (Shah P, 2005)
• Decreased disability (Victorian Study Group,
  1991)
• Decreased mortality (Kollee, 1999 Warner, 2004
  Lubchenco, 1989 Yeast, 1998 Cooper,
  1999Obladen, 1994 Johansson, 2004 Gerlinde,
  2005)

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But.

• Higher mortality at night in inborn units
• Better (40!) if in-house fellow or attending
  (Lee, SK, 2003)
• Observed mortality less in hospitals without
  residency programs and less volume (104 vs. 62)
  (Horbar JD, 1997)
• Outborn status protective in US Centers (NEOPAIN
  trial, Rao R, Hall RW, 2006)
• No difference in mortality after adjusting for
  prenatal steroids (NEOPAIN trial, Palmer KG, Hall
  RW, 2005)
• NEOPAIN trial required transfer within 7 hours

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Problems with Maternal Transport in Arkansas

• Rural state with long distances to travel in
  preterm labor
• Home for threatened preterm labor not well
  developed
• Evolving transport system with established
  neonatal transport system
• Hospital competition
• Money, pride, prestige

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Summation of literature

• Overwhelming support for regionalization
• Overwhelming support for maternal transport
• IVH always decreased in inborn population
• Selection bias a problem in all studies
• Refer patients who are survivable
• Outborn babies may require emergency delivery
• Abruption, Uterine rupture, prolapsed cord, etc

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ANGELS Referral

• Regionalization works
• A neonatologist does not an intensive care
  nursery make
• Hindrances to regionalization
• Money
• Prestige
• Why UAMS???

Palmer, Hall, et al, 2005 Fanaroff Martin, 7th
ed, 2002
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Why We Started Mortality Data from 1995-2000
ACH p0.039 for 500-600gms VtOx plt0.001 for
500-600gms NICHD plt0.001 for 500-600gms
ACH p0.087 for 600-700 gms VtOx p0.02 for
600-700gms NICHD plt0.005 for 600-700gms
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Why We Started Mortality Data From 1995-2000
ACH p0.0135 for 500-750
VtOx plt0.0001 for 500-750
NICHD plt0.0001 for 500-750
Vt Ox p0.0065 for 750-1000 NICHD p0.026 for
750-1000
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Why We Started IVH Data From 1995-2000
500-750 750-1000 1000-1250
1250-1500 ACH p0.047 p0.33 p0.002
p0.02 NICHD plt.0001 p.0004 p.0261 p.10
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Evidence

• Better outcomes with inborn delivery in AR
• Need for education
• Medicaid deliveries
• Large impact (55 coverage)
• Easy to work with
• Centralized

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Survival 2001-2004


plt0.05 plt0.01
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Survival 2001-2004
plt0.05 plt0.01




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Survival 2001-2004
plt0.01





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Survival 2001-2004
plt0.01 UAMS vs. all others
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Survival 2001-2004
Plt0.01 at all weights
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Grade 3 and 4 IVH Rate
plt0.05 plt0.01




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Why the Improved Outcomes at UAMS

• Maternal Transport
• Strong OB/Perinatal program
• ACH backup
• Nursing experience
• UAMS administration backup
• In house neonatal coverage
• Medicaid

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Number of UAMS VLBW Admissions
ANGELS
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What We Know

• UAMS has better survival in VLBW neonates
• Less IVH in the inborn population
• ANGELS has increased inborn delivery
• Back-up of ACH
• Medicaid is in a good position to advocate for
  better outcomes regardless of pride and prestige

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What We Must Research

• Cost
• Initial hospital
• Long term
• Long term outcome and satisfaction of families
• Quality of survival

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Conclusion

• ANGELS is building a better medical system
• IVH rates are markedly improved survival is
  modestly affected in the system
• More research is needed on long term outcomes and
  costs
• ANGELS/Medicaid is a smart, cost effective system
  who cares for her clients, especially compared to
  other programs (FEMA)
• Funding should remain intact for AHRQ, Medicaid,
  and ANGELS