Neonatal Length Of Stay Research Articles

Transcatheter and Surgical Ductus Arteriosus Closure in Very Low Birth Weight Infants: 2018-2022.

The optimal patent ductus arteriosus (PDA) closure method in very low birth weight (VLBW) infants is uncertain. In 2019, the first transcatheter occlusion device was approved in the United States for infants ≥700 g. We described survival and short-term outcomes among VLBW infants who underwent transcatheter or surgical PDA closure (2018-2022). Vermont Oxford Network members submitted data on infants born from 401 to 1500 g or 22 to 29 weeks' gestational age. Adjusted risk ratios (aRR) for survival, length of stay (LOS), prematurity complications, and discharge support were used to compare transcatheter versus surgical closure. Subgroup analyses were conducted for infants with birth weight ≥700 g and born in 2020-2022. Overall, 6410 of 216 267 infants at 726 hospitals received invasive PDA treatment. Transcatheter closure increased from 29.8% in 2018 to 71.7% in 2022. VLBW infants undergoing transcatheter closure had higher survival (adjusted rate ratio [aRR] 1.03; 1.02-1.04) with similar LOS (aRR 1.00; 0.97-1.03), neonatal complications (aRR 1.00; 0.98-1.01), and receipt of discharge support (aRR 0.94; 0.89-1.01). In subgroup analyses, survival (aRR 1.02; 1.00-1.04) and discharge support (aRR 0.90; 0.81-1.01) were similar between groups, whereas selected neonatal complications (aRR 0.95; 0.93-0.98) and LOS (aRR 0.95; 0.90-0.99) were lower after transcatheter closure. Transcatheter PDA closure in VLBW infants was increasingly used after 2018. Selected short-term outcomes for infants receiving transcatheter closure may be more favorable, compared with surgical, and warrants further clinical investigation.

Complicated Cellulitis is an Independent Predictor for Increased Length of Stay in the Neonatal Intensive Care Unit

To assess cellulitis in the neonatal intensive care unit (NICU) setting and identify risk factors for its disease severity and whether cellulitis influences length of stay (LOS). In this retrospective study, patients with cellulitis were identified using the electronic health record while admitted to the NICU at Massachusetts General for Children from January 2007 to December 2020. Demographic and clinical data were extracted from patient records. Two multivariable logistic regression models were constructed to assess for independent predictors for increased LOS (≥30days) and complicated cellulitis in the hospital. Eighty-four patients met the study criteria; 46.4% were older than 14days at the time of diagnosis of cellulitis, 61.9% were non-White, and 83.3% were born prematurely; 48.8% had complicated cellulitis as defined by overlying hardware (41.7%), sepsis (7.1%), requirement for broadened antibiotic coverage (7.1%), bacteremia (4.8%), and/or abscess (3.6%). The mean hospital LOS was 58.5±36.1days SD, with 72.6% having a LOS greater than 30days. Independent predictors of increased LOS were extreme prematurity (<28weeks' gestation) (OR: 14.7, P=.03), non-White race (OR: 5.7, P=.03), and complicated cellulitis (OR: 6.4, P=.03). No significant predictors of complicated cellulitis were identified. This study identifies complicated cellulitis in the NICU as an independent predictor of increased hospital LOS in neonates. Implementation of strategies to mitigate the development of cellulitis may decrease LOS among this high-risk population.

A case-based reasoning system for neonatal survival and LOS prediction in neonatal intensive care units: a development and validation study

Early prediction of neonates' survival and Length of Stay (LOS) in Neonatal Intensive Care Units (NICU) is effective in decision-making. We developed an intelligent system to predict neonatal survival and LOS using the "Case-Based Reasoning” (CBR) method. We developed a web-based CBR system based on K-Nearest Neighborhood (KNN) on 1682 neonates and 17 variables for mortality and 13 variables for LOS and evaluated the system with 336 retrospectively collected data. We implemented the system in a NICU to externally validate the system and evaluate the system prediction acceptability and usability. Our internal validation on the balanced case base showed high accuracy (97.02%), and F-score (0.984) for survival prediction. The root Mean Square Error (RMSE) for LOS was 4.78 days. External validation on the balanced case base indicated high accuracy (98.91%), and F-score (0.993) to predict survival. RMSE for LOS was 3.27 days. Usability evaluation showed that more than half of the issues identified were related to appearance and rated as a low priority to be fixed. Acceptability assessment showed a high acceptance and confidence in responses. The usability score (80.71) indicated high system usability for neonatologists. This system is available at http://neonatalcdss.ir/. Positive results of our system in terms of performance, acceptability, and usability indicated this system can be used to improve neonatal care.

Genetic Testing and Hospital Length of Stay in Neonates With Epilepsy

BackgroundWe evaluated changes in genetic testing for neonatal-onset epilepsy and associated short-term outcomes over an 8-year period among a cohort of patients in the neonatal intensive care unit (NICU) at a single institution before and after the introduction of sponsored genetic epilepsy testing in January 2018. MethodsOur primary outcome was a change in length of stay (LOS) after 2018. We also ascertained severity of illness with the Neonatal Sequential Organ Failure Assessment (nSOFA), type and result of genetic testing, turnaround time to molecular diagnosis (TAT), LOS, antiseizure medications (ASMs), and use of technology at discharge. We compared outcomes using nonparametric tests and difference-in-difference analysis. ResultsFifty-three infants with genetic testing were included; 20 infants were tested after 2018. A total of 4160 infants in the NICU without genetic testing were used as reference. In the genetic testing group, LOS was 25 days (interquartile range [IQR] 5, 49) pre-2018 and 19 days (IQR 6, 19) post-2018 (P < 0.001 when compared with the reference population in the difference-in-difference analysis). TAT decreased from 51 days to 17 days after 2018 (P = 0.003). ASM number decreased from 4 (IQR 2, 5) to 2 post-2018 (IQR 1, 3) (P = 0.02). Over the same time periods there was no significant change in birth weight, maximum nSOFA score, or technology dependence. ConclusionsIn this cohort, changes in genetic testing for neonatal-onset epilepsy were associated with shorter LOS that was not explained by changes in severity of illness, birth weight, or the average LOS in the NICU over time. Validation of these results in a larger, multicenter sample size is warranted.

Pilot study assessing the effect of osteopathic manipulative treatment (OMT) on length of stay in neonates after therapeutic hypothermia.

Term neonates treated with therapeutic hypothermia (TH) may experience delays in acquiring skills for oral feeding, thus prolonging hospital admission. To determine whether osteopathic manipulative treatment (OMT) can decrease the overall length of stay (LOS) for term neonates by accelerating the transition to full oral feeds. A pilot study was conducted to compare LOS in term neonates treated with OMT to matched historical controls. Eligibility criteria were gestational age greater than or equal to 37weeks, mild to moderate encephalopathy, absent seizure activity, and no brain injury on magnetic resonance imaging. Treated neonates had OMT twice between day of life four and seven, then twice per week on nonconsecutive days until hospital discharge. Secondary outcomes were to compare the number of days with nasogastric tube in both OMT and historically matched control groups and to characterize somatic dysfunction patterns in the primary affected areas of the craniosacral mechanism. Twelve of 28 neonates treated with TH between October 2017 and August 2018 met eligibility criteria for the study and were matched 3:1 to 36 historical controls. On average, mothers of neonates who received OMT were older than the historical control mothers (31.3years [SD, ±6.0] vs. 27.4 [SD, ±4.5]; p=0.02) Nineteen of the 36 historical control neonates, but no neonates in the OMT group, were intubated for a median of two days (interquartile range 1, 4). The mean LOS in the OMT group was 9.1 vs. 11.6days for historical controls (p=0.048); however, in a sensitivity analysis excluding intubated neonates from the historical controls, the difference was 9.1 vs. 10.1days (p=0.21). All neonates were orally feeding at discharge. Neonates given OMT had between two and four treatments lasting 8-20minutes. By the final treatment, the craniosacral mechanism's intraosseous and cranial base compressions and physiologic motion were improved. There were no adverse effects noted during OMT sessions. Our findings suggest that OMT performed on term neonates treated with TH may decrease the amount of time needed to acquire the necessary skills for oral feeding. Although this result was not statistically significant, it may be clinically significant. A larger prospective clinical trial may have the power needed to detect a statistically significant reduction in LOS and number of days to full oral feeds in this patient population.

Neonatal and Maternal Outcomes in Spontaneously-Conceived Twin PregnanciesAccording to Mode of Delivery.

Appropriate intrapartum conduct in a twin delivery remains a challenging aspect of obstetric practice. The objective of this study was to compare neonatal and maternal outcomes in twin pregnancies according to mode of delivery. This is a single centre retrospective cohort study of all consecutive spontaneously-conceived twin deliver-ies (≥ 24 weeks, estimated fetal weight ≥ 500 grams) over a nine-year period between 01/01/2007 - 31/12/2016 at a tertiary-level centre. Neonatal outcomes included survival, APGAR score, prematurity-associated pathology (PAP), admission to the neonatal intensive care unit (NICU) and length of stay (LOS). Maternal outcomes included postpartum complications and LOS. Statistical analysis comprised Chi-square test with subsequent p-value and odds-ratio with 95% confidence interval. Statistical significance was set at p<0.05. A total of 173 consecutive women with spontaneously-conceived twin deliveries were enrolled in this study, 129 (74.6%) women delivered by caesarean section (CS). The success rate of vaginal delivery (VD) was 93.6% (44/47). A strong statistical correlation was identified between CS and NICU admission; 53.2% vs. 1.5% (p=0.0001). Neonatal LOS in the NICU was significantly longer in the CS group. Prematurity-associated pathology (PAP) was noted in 75 pairs of twins (75/173); 61 pairs were delivered by CS, bearing strong statistical significance (p<0.0001). Postpartum complications occurred in 14.7% of CS compared to 13.6% of VDs. Neonates delivered by CS had a higher rate of PAP, NICU admission, lower birth weight and longer LOS. This study showed that VD is safe, especially when the first twin is in cephalic presentation.

Costs and Extra Length of Stay because of Neonatal Bloodstream Infection at a Teaching Hospital in Ghana.

BackgroundThere are no published studies on the costs of hospital-acquired neonatal bloodstream infection (BSI) in Ghana. Therefore, this study aims to calculate the cost and extra length of stay (LOS) of neonatal BSI. A prospective case–control study was undertaken at the neonatal intensive care unit (NICU) of Korle Bu Teaching Hospital (KBTH) in Ghana.MethodsThe clinical data of 357 neonates were prospectively analysed. Overall, 100 neonates with BSI and 100 control neonates without BSI were matched by weight, sex and type of delivery. The direct and indirect costs to neonates and their caregivers was obtained on a daily basis. The cost of drugs was confirmed with the Pharmacy Department at KBTH. A count data model, specifically negative binomial regression, was employed to estimate the extra LOS in the NICU due to neonatal BSI. The study analyzed the total, average and marginal costs of neonatal BSI for the case and control groups from the perspective of the patients/carers/providers.ResultsFifty-four percent of the total sample were born with a low birth weight. Neonates with BSI recorded higher costs compared with neonates without BSI. The highest difference in direct costs was recorded among neonates with extremely low birth weight (US$732), which is 67% higher than similar neonates without BSI. The regression estimates show a significant correlation between neonatal BSI and LOS in the NICU (p < 0.001). Neonates with BSI stayed an additional 10 days in the NICU compared with their matched cohort. The LOS varies significantly depending on the neonate’s weight at birth. The extra days range from 1 day for neonates defined as macrosomia to 15 extra days for extremely low birth weight neonates.ConclusionsNeonatal BSI was significantly associated with prolonged LOS. The continuous presence of experienced medical staff, as well as parents, to monitor newborns during their stay on the ward has enormous economic burden on both hospitals and caregivers.

Financial Support to Medicaid-Eligible Mothers Increases Caregiving for Preterm Infants.

To assess the impact of financial support on maternal caregiving activities for preterm infants. We conducted a small randomized controlled trial (RCT) in two Massachusetts Neonatal Intensive Care Units (NICUs). We enrolled 46 Medicaid-eligible mothers of preterm infants between January 2017 and June 2018 and randomly assigned them to a treatment group (up to 3 weekly financial transfers of $200 each while their infant was in the hospital) or a control group. We collected hospital-record data while the infant was admitted. The primary outcome was a binary variable indicating skin-to-skin care (STSC) was provided during a hospital day. Secondary outcomes included daily maternal visitation, daily provision of breastmilk, neonatal growth and length of stay(LOS). Multilevel generalized linear models with random effects were used to estimate treatment effects on daily maternal behaviors and ordinary least squares models were used to estimate impacts on neonatal growth and LOS. We assigned 25 women to the intervention and 21 to the control and observed them over 703 days of their infants' hospitalization. Mothers who received financial support were more likely to provide STSC (adjusted risk ratio: 1.85; 95% confidence interval [CI] 1.31-2.62) and breastmilk (adjusted risk ratio: 1.36; 95% CI 1.06-1.75) while their infant was in the NICU. We see no statistically significant impact on neonatal growth outcomes or LOS, though estimated confidence intervals are imprecise. Our evidence demonstrates the potential for financial support to increase mothers' engagement with caregiving behaviors for preterm infants during the NICU stay.

(35) Factors Contributing to Increased Length of Stay and Cost of Care in Children’s Hospitals vs. Non-Children’s Hospital for Neonatal Hypoxic-ischemic Encephalopathy in the United States in 2012

Purpose of Study: To investigate the difference in length of stay (LOS) and cost among children’s hospitals and non-children’s hospitals when caring for neonates with hypoxic-ischemic encephalopathy (HIE). Since the establishment of therapeutic hypothermia (TH) as standard care for neonatal HIE, LOS and cost for management of neonatal HIE has not been thoroughly investigated. Methods Used: Neonates diagnosed with HIE, defined by ICD-9-CM codes, were extracted from the 2012 national Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID). We excluded patients that transferred out from their care facility and those with …

Prenatally diagnosed omphalocele: characteristics associated with adverse neonatal outcomes

To characterize factors associated with adverse neonatal outcomes in prenatally diagnosed omphalocele cases. Prenatally diagnosed omphalocele cases at a single referral center from 1 January 2009 to 31 December 2017 were retrospectively reviewed. Clinical variables and antenatal imaging measurements were collected. Associations between prenatal and neonatal characteristics and the adverse outcome of death or prolonged length of stay (LOS) were analyzed. Out of 63 fetal cases, 33 were live-born, > 50% had other anomalies, and neonatal mortality was 12%. Adverse outcomes were associated with neonatal variables, including lower median 1-min Apgar score, initial mechanical ventilation, and late-onset sepsis, but not approach toomphalocele closure. With multivariate analysis, death or prolonged LOS was associated only with low lung volumes by fetal MRI (OR 34 (3-422), p = 0.006). Low lung volumes by fetal MRI were associated with death or prolonged LOS in neonates with prenatally diagnosed omphalocele and may guide clinicians with counseling families.

The effect of standardizing treatment when managing neonatal abstinence syndrome

Objective: Standardizing treatment of neonatal abstinence syndrome (NAS) is currently recommended; however, single institution prospective studies are lacking regarding the success of this approach. The study objective was to evaluate overall newborn response and length of stay (LOS) of neonates treated for NAS following the institution of a strict standardized treatment protocol.Methods: From 1 January 2014 to 30 June 2016, a prospective cohort study was performed collecting neonatal outcomes before and after the standardization of a strict NAS morphine weaning treatment protocol. The primary outcome measure was length of stay. The standardized protocol was fully instituted in June 2015.Results: A total of 395 neonates were treated for NAS during the study. The LOS for the 17 months prior to the initiation of this protocol was 23.31 (±6.2) days (233 neonates). The LOS in the 13 months after protocol initiation was 18.17 (±5.1) days (162 neonates). This was a difference of 5.14 days (95%CI 4.0–6.3 days) less in LOS (p < .0001).Conclusions: These data demonstrate that the initiation of a standardized NAS treatment protocol can significantly improve neonatal response and decrease LOS. It is recommended that institutions with nurseries that treat infants with NAS develop standardized treatment protocols to improve care for this complicated patient population.

Regional Differences in Cost and Length of Stay in Neonates with Hypoplastic Left Heart Syndrome.

Hypoplastic left heart syndrome (HLHS) is a highly resource-intensive diagnosis. Geographic variation in cost and length of stay (LOS) in HLHS is not well described. Neonates diagnosed with HLHS between 2000 and 2012 were identified using the Kids' Inpatient Database. Hospitalizations were stratified into two groups: (1) birth and (2) secondary. United States regional differences in hospital charges and LOS were compared using adjusted linear regression. Of 2431 birth hospitalizations, 449 neonates (18.5%) died while inpatient and mortality rates differed by region (p = 0.02). After birth, 40.5% (n = 985) of neonates were transferred; transfers were most common in the Midwest (p < 0.0001). Adjusted average LOS was shortest in the West and longest in the South (26.1 days; 95% CI 24.0, 35.1 vs. 34.9 days; 95% CI 31.8, 38.1). Average adjusted charges were lowest in the Northeast ($324,600; 95% CI $271,400, $377,900) and highest in the West ($400,500; 95% CI $346,700, $454,300, p = 0.05). Among 1895 secondary hospitalizations, 24.9% of neonates died as inpatients, and the average adjusted LOS was shortest in the West (26.8 days; 95% CI 23.9, 29.7) and longest in the South (38.5 days; 95% CI 34.4, 42.4). Average adjusted charges were lowest in the Northeast ($326,900; 95% CI $270,700, $383,100) and highest in the South ($505,900; 95% CI $450,200, $561,500, p < 0.0001). Significant geographic variations in mortality, LOS, and hospital charges exist in care of US HLHS neonates. Reducing variation in care should remain a priority in national quality efforts in congenital heart disease.

Racial variations in Cost, Total Charges and Length of Stay in neonates with gastroschisis in the United States 1997-2012

Racial variations in Cost, Total Charges and Length of Stay in neonates with gastroschisis in the United States 1997-2012

Targeted delivery at 34 versus 35 weeks in women with preterm prelabor rupture of membranes

Objective: To compare planned delivery at 34 versus 35 weeks for women with preterm prelabor rupture of membranes (PPROM).Materials and methods: We performed a retrospective cohort study of singleton pregnancies with PPROM after 24 weeks delivered from 2006 to 2014. In 2009, an institutional practice change established 35 weeks as the target gestational age before induction of labor was initiated after PPROM. Demographic and outcome measures were compared for two cohorts: women delivered 2006–2008 – target 34 weeks (T34) and women delivered 2009–2014 – target 35 weeks (T35). The primary outcome was neonatal intensive care unit (NICU) admission.Results: Of the 382 women with PPROM, 153 (40%) comprized the T34 cohort and 229 (60%) comprized the T35 cohort. Demographic characteristics were similar between groups. There were no differences between groups in gestational age at PPROM (31.0 ± 3.3 weeks versus 31.2 ± 3.1 weeks; p = .50) or maternal complications. The mean gestational age at delivery was earlier in the T34 group (31.8 ± 3.2 weeks versus 32.4 ± 2.7 weeks; p = .04). The median predelivery maternal length of stay (LOS) was 1 day longer in the T35 group (p = .03); the total and postpartum LOS were similar between groups (p > .05). There were no differences in the rate of NICU admission (T34 89.5% versus T35 92.1%; p = .38) or median neonatal LOS (T34 14 days versus T35 17 days; p = .15). In those patients who reached their target gestational age, both maternal predelivery LOS and total LOS were longer in the T35 group (p > .05). The frequency of NICU admission in those reaching their target gestational age was similar between groups (T34 83.37% versus T35 76.19%; p = .46).Conclusions: A 35-week target for delivery timing for women with PPROM does not decrease NICU admissions or neonatal LOS. This institutional change increased maternal predelivery LOS, but did not increase maternal or neonatal complications.

Neonatal Abstinence Syndrome Among Infants Born to Mothers With Sickle Cell Hemoglobinopathies [3R

INTRODUCTION: The objective of this study is to examine risk factors for neonatal abstinence syndrome (NAS) among infants born to mothers with sickle cell hemoglobinopathies (SCH). METHODS: This is a retrospective case-control study of non-anomalous, singleton infants born to mothers with laboratory confirmed SCH and placental pathology results. Infants were included if they were diagnosed with NAS prior to hospital discharge. The outcome of interest was the association of maternal variables with NAS. RESULTS: The occurrence of NAS was 4% (n=5). Mothers with NAS were more likely to have SC disease (80%) compared to other SCH (20%). Mean weeks gestational age (wga) at delivery was 37 ± 2; and did not differ among NAS affected infants compared to infants without NAS (p=0.51). Likewise, the infant's hospital length of stay (LOS) did not differ between infants with NAS (11 ± 4 days) compared to unaffected infants (8 ± 18 days), p=0.3. A preterm birth rate of 21% associated with prolonged NICU admissions may contribute to similar neonatal LOS. Fifteen women had antepartum (AP) admissions for pain and/or sickle crisis. Of these patients, 4 infants (29%) were diagnosed with NAS. The median maternal AP LOS for women with infants diagnosed with NAS was 132 (61, 164) days compared to women who were admitted for pain but whose infants were not diagnosed infants with NAS: 7.5 (4, 12) days (p &lt; 0.001). CONCLUSION: Incidence of NAS among mothers with sickle cell hemoglobinopathies is low; severe disease requiring prolonged AP admission for pain control significantly increases the risk of NAS.

685: Can a standardized labor protocol for induction reduce adverse outcomes without increasing risk of cesarean?

To evaluate the impact of a labor protocol on reducing maternal and neonatal morbidity in women undergoing an induction of labor (IOL) with an unfavorable cervix. As part of a planned secondary analysis, we compared maternal/neonatal morbidity between women in a large randomized trial on IOL (n=488) that included a detailed labor protocol to women in an observational cohort (n=362) enrolled at the same time where labor was managed at the discretion of the provider. The labor protocol included standardized and active management of latent/active labor and encouraged close attention to the rate of cervical change with recommendations for interventions at particular time points (eg. Oxytocin, intrauterine pressure catheter, amniotomy, cesarean). Term (≥37 weeks) singletons with intact membranes and unfavorable cervix (dilation ≤2cm, Bishop score ≤6) were included. Adjusted relative risk (RR) of cesarean, maternal morbidity, NICU admission, and NICU admission >48 hrs was estimated using modified Poisson approach. Adjusted incident rate ratios (IRR) for length of stay (LOS) were estimated using Poisson and negative binomial models. Demographic characteristics (eg. age, BMI, insurance) were different between protocol and observational groups but clinical characteristics were mostly similar (gestational age at IOL, indication for IOL, co-morbidities, Bishop score). Median cervical dilation at the time of induction was slightly greater in the protocol group (1cm [1-1.5] vs. 1cm [0.5-1.5], p<0.001). When comparing differences in adverse outcomes, there was a decreased risk of maternal morbidity and a shortened neonatal LOS in the protocol group (Table). However, there were no differences in risk of cesarean, maternal LOS, or NICU admission. Use of a standardized and active management labor protocol for women undergoing a term IOL with an unfavorable cervix is associated with a reduction in maternal morbidity and neonatal length of stay without an increase in cesarean.

What factors predict length of stay in a neonatal unit: a systematic review

ObjectiveIn the UK, 1 in 10 babies require specialist neonatal care. This care can last from hours to months depending on the need of the baby. The increasing survival of...

Proportion of neonatal readmission attributed to length of stay for childbirth: a population-based cohort study

ObjectiveMost literature on length of stay (LOS) for childbirth focuses on ‘early’ discharge as opposed to ‘optimal’ time of discharge and has conflicting results due to heterogeneous definitions of ‘early’...

Universal bilirubin screening and health care utilization.

To evaluate the impact of the implementation of universal bilirubin screening on neonatal health care use in the context of a large jurisdiction with universal health insurance. We conducted a population-based retrospective cohort study of all newborns discharged after birth between April 2003 and February 2011 from 42 hospitals that implemented universal bilirubin screening between July 2007 and June 2010 in Ontario, Canada. We surveyed hospitals to determine their screening implementation date. We used multiple linked administrative health data sets to measure phototherapy use, length of stay (LOS), jaundice-related emergency department visits, and jaundice-related readmissions. We modeled the relationship between universal bilirubin screening and outcomes using generalized estimating equations to account for clustering by hospital, underlying temporal trends, and important covariates. Screening was associated with an increase in phototherapy during hospitalization at birth (relative risk, 1.32; 95% confidence interval, 1.09-1.59) and a decrease in jaundice-related emergency department visits (relative risk, 0.79; 95% confidence interval, 0.64-0.96) but no statistically significant difference in phototherapy after discharge, LOS, or jaundice-related readmissions after accounting for preexisting temporal trends in health care service use and other patient sociodemographic and hospital characteristics. Universal bilirubin screening may not be associated with increased neonatal LOS or increased subsequent hospital use. Our findings are relevant for determining the resource implications of universal bilirubin screening in Ontario. They highlight the limitations in generalizability of previous research on health care utilization associated with similar programs and underline the importance of context-specific local evaluation of guideline implementation.

Time Trends and Payer Differences in Lengths of Initial Hospitalization for Preterm Infants, Arkansas, 2004 to 2010

The objective of this study was to examine the time trend in length of stay (LOS) and explore potential differences in neonatal LOS by insurance type for preterm infants in Arkansas between 2004 and 2010. There were 18,712 preterm infants included in our analyses. Accelerated failure time models were used to model neonatal LOS as a function of insurance type and discharge year while adjusting for key maternal and infant characteristics, and complication/anomaly indicators. Before adjusting for the complication/anomaly indicators, the LOS for preterm infants delivered to mothers in the Medicaid group was 3.2% shorter than those in the private payer group. Furthermore, each subsequent year was associated with a 1.6% increase in the expected LOS. However, after accounting for complications and anomalies, insurance coverage differences in neonatal LOS were not statistically significant while the trend in LOS persisted at a 0.59% increase for each succeeding year. All of the apparent differences in LOS by insurance type and more than half of the apparent increase in LOS over time are accounted for by higher rates of complications among privately insured preterm infants and increasing rates of complications for all surviving preterm infants between 2004 and 2010.