Clinical Instructor, Pediatrics - Neonatal and Developmental Medicine
OBJECTIVE: To examine changes in referral rates of very low birthweight (birthweight <1500g) 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 ?33weeks of gestation, with a birthweight of 1251-1500g, 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.
View details for DOI 10.1016/j.jpeds.2019.08.050
View details for PubMedID 31587859
Identify clinical factors, transport characteristics and transport time intervals associated with clinical deterioration during neonatal transport in California.Population-based database was used to evaluate 47,794 infants transported before 7 days after birth from 2007 to 2016. Log binomial regression was used to estimate relative risks.30.8% of infants had clinical deterioration. Clinical deterioration was associated with prematurity, delivery room resuscitation, severe birth defects, emergent transports, transports by helicopter and requests for delivery room attendance. When evaluating transport time intervals, time required for evaluation by the transport team was associated with increased risk of clinical deterioration. Modifiable transport intervals were not associated with increased risk.Our results suggest that high-risk infants are more likely to be unstable during transport. Coordination and timing of neonatal transport in California appears to be effective and does not seem to contribute to clinical deterioration despite variation in the duration of these processes.
View details for DOI 10.1038/s41372-019-0488-5
View details for PubMedID 31488902
BACKGROUND: Intraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.METHODS: Population-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.RESULTS: Among 20,927 infants, 4,818 (23%) had IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% CI 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P<0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).CONCLUSION: Pre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand contributing maternal factors.Pediatric Research accepted article preview online, 06 April 2018. doi:10.1038/pr.2018.47.
View details for PubMedID 29624572
Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.
View details for DOI 10.1016/j.clp.2018.01.013
View details for PubMedID 29747881
View details for PubMedID 28984877