Perinatal Regionalization Research Articles

Epidemiology of neonatal necrotising enterocolitis: a population‐based study

We examined the birthweight-, gender- and race-specific incidence as well as the biodemographic and clinical correlates of necrotising enterocolitis (NEC) in a well-defined six-county perinatal region in upstate New York. We conducted a retrospective, 8-year population-based survey to identify all cases of proven NEC (modified Bell stage II and above) in the area's regional neonatal intensive care unit (NICU). The denominator used to calculate the incidence was obtained from the Statewide Planning Research Cooperative System. Incidence was expressed as cases per 1000 live births. A total of 85 documented cases of proven NEC was identified in a six-county perinatal region that experienced 117 892 live births during the 8-year period. The average annual incidence was 0.72 cases per 1000 live births [95% CI 0.57, 0.87 per 1000 live births]. The highest incidence of NEC occurred among infants weighing 750-1000 g at birth and declined with increasing birthweight. The urban county had a 1.53 times higher risk of NEC than rural counties [95% CI 0.9, 2.6]. The overall incidence of NEC for non-Hispanic blacks was significantly greater than that for non- Hispanic whites (2.2 vs. 0.5 cases per 1000 live births, P = 0.00). The differences remained statistically significant even after correction for birthweight. Most cases (93%) in this series were preterm (gestational age <37 weeks). Only two patients were never fed before the diagnosis of NEC was confirmed. Positive blood cultures were documented in 27% of the cases with a predominance of Gram-negative enteric micro-organisms. NEC remains an important health problem especially for preterm infants and the non-Hispanic black population.

Which nurseries currently care for ventilated neonates in Illinois and Wisconsin? Implications for the next generation of perinatal regionalization.

We were interested in the extent to which advances in the availability of neonatalogy expertise have provided a centrifugal impetus to perinatal care. Specifically, we wondered where infants who were sick enough to require mechanical ventilation were currently being managed. We surveyed 116 of 140 hospitals in Illinois and Wisconsin that offered obstetric/newborn services in 1998-1999. The 23 Level I nurseries were consistently small, and offered virtually no "advanced" neonatal intensive care unit (NICU) technology. The 16 Level III NICUs were consistently large, offered advanced technology and personnel, and received sick infants from many hospitals in their regional network. The 77 Level II nurseries (two thirds of all hospitals with newborn services) were less consistently characterized. In general, Level II nurseries were a "spoke" (not a hub), and did not offer extracorporeal-membrane oxygenation (ECMO), nitric oxide (NO), or cardiovascular (CV) surgery. However, 19 (25%) of 77 Level II centers self-designated as "Level II+". These were significantly more likely to offer ventilators, percutaneous central venous catheters (PCVCs), total parenteral nutrition (TPN), and surgery. Fifty-three percent (18/34) of all nurseries offering mechanical ventilation self-designated as a Level II or II+, as opposed to Level III. Facile inferences about the appropriate role of Level II centers derived from decades-old data are probably unsupportable. It is time to acknowledge the distinction between the Level II nursery of the past and the newly evolving Level II+ NICUs.

Managed Care and Perinatal Regionalization in Washington State

Managed Care and Perinatal Regionalization in Washington State

Managed care and perinatal regionalization in Washington State

Objective: To determine if an association exists between managed care penetration and perinatal deregionalization in Washington State. Methods: The proportions of low birth weight (LBW) and very low birth weight (VLBW) deliveries were tabulated for each hospital in Washington State for the years 1989, 1993 and 1996. Level of perinatal care, degree of health maintenance organization (HMO) penetration, and maternal demographic characteristics including age, race, smoking, and Medicaid status were derived from state and national databases. Multiple linear regression analysis was performed for each hospital level to evaluate the association between change in proportion of LBW and VLBW deliveries and change in HMO penetration per hospital between each of the 3 years. Results: From 1989 through 1993, the proportion of LBW deliveries significantly declined at level III hospitals and rose at level I and II hospitals. This trend reversed between 1993 and 1996. Very low birth weight deliveries demonstrated more limited and somewhat contrary results, significantly decreasing, then increasing in level I hospitals, and significantly increasing in level III hospitals from 1989 to 1993. After controlling for changes in maternal characteristics over time, changes in HMO penetration at the hospital level were not significantly associated with an increasing proportion of LBW or VLBW deliveries at nonlevel III hospitals. In some analyses, increasing HMO penetration actually was significantly associated with decreasing LBW and VLBW deliveries at nonlevel III hospitals. Conclusion: Despite continued growth in HMOs throughout the state, the trend toward deregionalization in Washington State noted in the early 1990s has not continued. At the hospital level, the increasing presence of HMOs is not significantly associated with perinatal deregionalization.

Racial and ethnic disparities in the discordance between women's assessment of the timing of their prenatal care entry and the first trimester standard.

The purpose of this study was to investigate whether the discordance between women's assessment of the adequacy of the timing of their prenatal care entry and the standard of first trimester initiation was associated with maternal race or ethnicity. A population-based surveillance system, the California Pregnancy Risk Assessment Monitoring System, provided data on a stratified random sample of 4,987 women. The women delivered live-born infants from 1994-95 in three perinatal regions. Respondents completed an in-hospital, self-administered questionnaire. Weighted data were analyzed with multiple logistic regression. Twenty-two percent of the women in the sample initiated prenatal care after the first trimester of pregnancy (n = 1,097). Among the women with untimely care, 57% (n = 591) were satisfied with the time of care initiation. Discordance between the women's perception of the adequacy of the time of care initiation and the public health standard of first trimester initiation was associated with maternal ethnicity. After controlling for potential confounders, Mexican-born women with untimely care were more likely to report being satisfied with the time of initiation than were white non-Latina women with untimely care (OR = 4.03, CI = 2.46, 6.59). The design of public health interventions to increase the timeliness of prenatal care initiation will require a greater understanding of pregnant women's own perceptions of their needs for prenatal care, and the differences in perceptions across ethnic groups.

Differential Markers for Regionalization

To examine the site of delivery for very low birth weight (VLBW) infants and infants with major congenital malformations (MCM) within an established system of perinatal regionalization. A retrospective study of site of delivery for VLBW infants and infants born with MCM (tracheoesophageal fistula/esophageal atresia, diaphragmatic hernia, or gastroschisis/omphalocele) from 1990 through 1995 in Ohio. A total of 59.8% of VLBW infants and 36.1% of MCM infants were born in a level III hospital. There was a significant trend toward a decrease in VLBW infants (p < 0.01) and an increase in MCM infants (p < 0.05) born in a level III hospital between 1990 and 1995. There were significant regional variations among the six perinatal regions in Ohio in the proportion of both VLBW and MCM infants born in a tertiary center. Using the traditional marker of VLBW to assess regionalization in one state, we found significant variation in site of delivery among the perinatal regions and over the time course of the study. The delivery of infants with MCM at level III centers may be an alternative measure of regionalization.

Very Low Birth Weight Births At Non-NICU Hospitals: The Role of Sociodemographic, Perinatal, and Geographic Factors

The purpose of this study was to assess the extent of variation in the percentage of very low birth weight (VLBW) infants born at perinatal Level 1 hospitals (no Neonatal Intensive Care Unit [NICU]) across California's nine geographic Perinatal regions. The role of sociodemographic, perinatal, and geographic factors was also assessed. Multivariate analysis of California birth certificate files between 1989 and 1993, for 24,094 live-born infants weighing between 500 and 1499 gm, was conducted to identify factors associated with delivery at a Level 1 hospital. Analyses specific for race and ethnicity were also conducted for Hispanic, African American, and white cohorts. In the 5-year study period, 1989 through 1993, 10.5% (24,094) of all live-born VLBW infants were delivered in Level 1 hospitals. Significant variation across regions was evident, ranging from a regional low of 3.1% to a high of 24.3%. After controlling for multiple factors, the odds of delivering at a Level 1 hospital were decreased for African Americans and South East Asians and increased in Hispanic women as compared with white non-Hispanic women. For all women, less then adequate prenatal care, living in a 50% to 75% urban zip code, and living greater then 25 miles from the nearest NICU significantly increased the odds of VLBW delivery at a Level 1 hospital. For Hispanics, teen pregnancy and having two or more prior infant deaths increased the odds, whereas Medi-Cal as the payer source for delivery and two or more pregnancy complications decreased the odds of a Level 1 VLBW delivery. After taking these factors into account, when compared with Los Angeles, the odds of inappropriate delivery site ranged from 0.37 to 2.75 across California's nine geographic perinatal regions. Of this variation, 78% could be accounted for by the percentage of total births that delivered at a region's Level 1 hospitals. The overall state average of 10.5% deliveries of VLBW at Level 1 hospitals, although close to the 10% national objective for the year 2000, did not indicate the wide variation seen across California's nine geographic regions. Risk-adjusted regional differences in the likelihood of inappropriate delivery site for the high-risk VLBW infants suggest that reaching the Healthy People 2000 objective will require further strengthening of California's perinatal regional networks, especially in those regions where a high percentage of total births deliver at Level 1 hospitals.

Two Models of Perinatal Regionalization: One fashionable, Both Functional? † 1280

Centripetal referral of newborns requiring mechanical ventilation to tertiary NICUs has been the established model of perinatal regionalization for roughly twenty years. Data justifying this model are mostly of the same vintage. We wondered whether advances in technology, pharmacology, and skill allowed for alternative regionalization models of equivalent efficacy.

Changing patterns in regionalization of perinatal care and the impact on neonatal mortality

OBJECTIVE: Our goal was to study changing patterns of low-birth-weight outcome over the past decade as deregionalized perinatal care has occurred. STUDY DESIGN: Live births and neonatal mortality for two 5-year periods (1982 to 1986 vs 1990 to 1994) were calculated by hospital of delivery in the state of Missouri. Self-designated level of perinatal care was contrasted with number of deliveries and nursery census to evaluate outcome. Regression models were constructed to compare outcome between levels of care. RESULTS: There has been a significant shift of deliveries into self-designated level II and III perinatal centers. However, this is largely a result of redesignation of care rather than an actual increase in acuity or census. The relative risk of neonatal mortality for very-low-birth-weight infants is 2.28 in level II centers compared with level III centers, and is unchanged (2.57) from 10 years earlier. Nearly 14% of very-low-birth-weight deliveries still occur at non–level III centers. CONCLUSION: Changing patterns of perinatal regionalization have not improved outcome for inborn infants <1500 gm except in level III centers. Attempts should be made to deliver very-low-birth-weight infants in level III centers. (Am J Obstet Gynecol 1998;178:131-5.)

Quality assessment of perinatal regionalization by multivariate analysis: Illinois, 1991–1993

To identify (1) those elements in the infrastructure of a regionalized perinatal network that have independent effects on the variation in perinatal mortality among nontertiary units (member level I and II hospitals) and (2) shortcomings, if any, in a traditional perinatal data base that impede quality assessment of contemporary regionalized care. We analyzed perinatal surveillance data for 3 years, from 1991 to 1993, in the state of Illinois, representing more than 190,000 annual births. Fetal death and neonatal mortality rates for the 97 nontertiary hospitals studied were the dependent variables of interest. Two sets of independent variables were studied, those assessing the maternal sociobehavioral risk of populations served and those assessing the network infrastructure (defined as the facilities of member hospitals and their function within the regionalized network). We used multivariate analysis to partition the variation in hospital rates of perinatal mortality into two components, one attributable to maternal sociobehavioral risk and the other to the network infrastructure. Maternal sociobehavioral risk alone explained 73% of the variation in hospital fetal death rates and 38% of that in hospital neonatal mortality rates. When controlling for maternal sociobehavioral risk, rates of inborn very low birth weight (VLBW) deliveries (P < .001) and neonatal transport (P = .01) had independent effects on the variation in hospital fetal death rate; rates of inborn VLBW deliveries (P < .001), neonatal transport (P < .001), and proportion of VLBW infants transported out (P = .029) had independent effects on the variation in hospital neonatal mortality rate. In this mature statewide network, the rate of inborn VLBW deliveries exerted the strongest independent effect on variation in level I and II hospital rates of both fetal death and neonatal mortality. However, that there was such a large effect from maternal sociobehavioral risk alone has important public health implications. Additions and modifications to traditional perinatal surveillance are suggested better to assess the quality of regionalization in a contemporary health care environment.

Quality assessment of perinatal regionalization: State of illinois, 1991–1993

Quality assessment of perinatal regionalization: State of illinois, 1991–1993

Can and Should Level II Nurseries Care for Newborns Who Require Mechanical Ventilation?

Perinatal regionalization was conceived roughly 25 years ago to provide centralized care for critically ill newborn infants. As for many 25-year-old concepts, the obligatory centripetal design of many regionalization policies may need to be modified. This article presents the outcomes of 408 surviving patients who required mechanical ventilation (136 born in one community hospital and 272 birthweight-matched infants born in our tertiary center), and were cared for in our perinatal network. Mechanical ventilation of a resident population of newborns at a community NICU appeared to be as effective as ventilatory care at a regionalized tertiary neonatal intensive care unit, when assessed by comparing birthweight-matched populations for length of hospital stay, days on ventilator, and the need for home O2. Some may still claim that every baby who requires mechanical ventilation must be transferred to a tertiary care center. In an era of heightened interest in health services, health outcomes, and cost-effectiveness analysis, however, the authors believe that such claims will be subjected to increasing scrutiny. Our study represents a first attempt at determining the shape such scrutiny might take, and the sort of data analyses that may be required to reformat a perinatal network.

Perinatal Regionalization Versus Hospital Competition: The Hartford Example

The increasingly competitive health care environment may undermine effective traditional regional organizations. It is urgent to document the benefits of perinatal regionalization for the emerging health care system. We present a case study that illustrates many of the challenges to and benefits of perinatal regionalization in the 1990s. The controversy in Hartford was sparked by a proposed merger of two major pediatric services into a full-service children's hospital. Community hospitals reacted with plans to upgrade their obstetrics/neonatal facilities toward level II (intermediate) or II+ (intensive) neonatal intensive care units (NICUs). The fear that unrestricted competition would drive up overall health care costs prompted the hospital association and Chamber of Commerce to retain consultants to evaluate the number and location of regional NICU beds. The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges. The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization. Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics.

This study assessed the impact of mother's race, insurance status, and use of prenatal care on very low birthweight infant delivery in or transfer to hospitals with neonatal intensive care units (ICUs). Multivariate analysis of Alabama vital statistics records between 1988 and 1990 for infants weighing 500 to 1499 g was conducted, comparing hospital of birth and maternal and infant transfer status, and controlling for infant birthweight and for maternal pregnancy history and demographic characteristics. With other factors adjusted for, non-White mothers with early prenatal care were more likely than White mothers to deliver their very low birthweight infants in hospitals with neonatal ICUs without transfer. Among the mothers who presented first at hospitals without such facilities, those who had late prenatal care were less likely than those with early care to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for White women. Likelihood of infant transfer was not associated with these maternal characteristics. Maternal race, prenatal care use, and insurance status may influence the likelihood that very low birthweight infants will have access to neonatal intensive care. Interventions to improve perinatal regionalization should address individual and system barriers to the timely referral of high-risk mothers.

Performance-based management in local health departments: measuring the success of implementation.

Six of eight local health departments in North Carolina's Southwest Perinatal Region III participated in a PBMS demonstration project also involving the state health department, the Centers for Disease Control, and the School of Public Health of the University of North Carolina at Chapel Hill. In all six counties the problem of reducing prematurity and low birthweight was selected to test this innovation. Using standardized instruments, staff awareness of and concern for low birthweight problems and programs were measured, as was level of success of implementation of PBMS. Factor analysis of three rounds of Awareness and Concern responses produced three uncorrelated factors: awareness of low birthweight problems, awareness of low birthweight programs, and concern for low birthweight. The results suggest that the PBMS increased awareness of the problem and the program, and that the project succeeded in half of the counties, helped some counties achieve some goals, and provided some benefits to some counties. The implications for Total Quality Management are discussed.

Toward Improving the Outcome of Pregnancy, 1993: Perinatal Regionalization Revisited

Toward Improving the Outcome of Pregnancy: The 90s and Beyond (TIOP II) was released by The March of Dimes Birth Defects Foundation (MOD) in May of this year. A predecessor, TIOP I, released in 1976 by the MOD, is considered to be the cornerstone document for the structure of the regional perinatal care system present in the United States today. Revisitation of our approach to perinatal care took place because we know we have a persistent problem with perinatal outcomes in the United States. Our perinatal statistics lag behind those reported by many other nations. We know we should do better and are becoming frustrated with relative lack of progress. Infant mortality is an indicator that has attracted professional concern and national initiatives. It has been placed on local political agendas and discussed frequently in the media of cities such as Boston and Washington.

Rethinking Perinatal Policy: History and Evaluation of Minimum Volume and Level-of-Care Standards

Two standards have played a dominant role in policies to organize U.S. perinatal care. Minimum volume (or size) and service levels according to technical capacity have been major components of perinatal regionalization and other reorganization efforts. These standards are consistent with structural definitions of quality of care, but not necessarily with quality definitions according to outcome. Empirical research has not demonstrated a general association between the standards and improved perinatal outcomes, although it has demonstrated improved outcomes for very low birthweight babies. The standards have contributed to the growth and financial stability of tertiary-level services, but economy in terms of lower unit costs has also not been demonstrated. These discrepancies between research findings and the paradigm of a system of large, complex centers have led to conceptual errors in explaining findings, but they have also led to a recognition of uncertainty concerning perinatal service organization.

Analysis of a Maternal Transport Service Within a Perinatal Region

In 1979, the State of Illinois legislated regionalization of perinatal care. Analysis of perinatal statistics from the Loyola University Perinatal Center from 1979 to 1986 supports: (1) increasing numbers of maternal and neonatal transports, with the number of maternal transports exceeding the number of neonatal transports since 1982; (2) increasing proportion of low birthweight and very low birthweight infants delivered at the perinatal center; (3) a decrease in the number of infants less than 1500 gm sent as neonatal transports; and (4) increasing proportion of neonatal transports with a birthweight greater than 2500 gm. With the change in utilization by local physicians, the perinatal center has expanded its obstetric and neonatal service areas and hired additional staff to meet the increased demand for its services. The perinatal mortality rate for the region has decreased from 1981 to 1986.

Survival and ventilatory course of a regional cohort of very low birthweight (501-1500 gm) infants.

To minimize the selection bias inherent in reporting results gathered only in neonatal intensive care units, this study presents survival and respiratory course data on all 299 infants of birthweight 501 to 1500 gm liveborn to residents of the North Central Illinois Perinatal Region in 1985-1986. The survival rate was 86.8% (171 of 197) for infants between 1001 and 1500 gm, but only 35.3% (36 of 102) for infants weighing less than 1001 gm. In all, 207 infants (69.2%) survived. One hundred eighty-six infants (62.2%) required mechanical ventilation, and 122 (65.6%) ventilated infants survived. Seventy-five (40.3%) ventilated infants developed lung rupture and 54 (29%) developed chronic lung disease (CLD), as manifest by a supplemental oxygen requirement at 28 days of age. Lung rupture significantly predicted death in the first 7 days, the development of CLD, and fatal CLD. These data portray an accurate picture of the survival and ventilatory course of this group of babies because every member of the entire regional cohort is included.

Neonatal Seizures After Cesarean Delivery

A study was done on the occurrence of neonatal seizures in 14,367 infants delivered by cesarean section in a perinatal region in 4 years. Although seizures occurred in 1% of all of these infants, small infants weighing 4%). Term infants delivered before labor (repeat cesarean section) had the lowest seizure rate (