REGISTER TODAY! // CPQCC?s First Annual ?IMPROVEMENT PALOOZA? ? A deep dive into the exciting world of quality improvement. // March 6, 2020 at Cool Topics in Neonatology // Coronado Island Marriott Resort

For those interested in neonatal resuscitation:

NRP is heading your way! The NRP Steering Committee is hosting a special 1-day instructor workshop in several locations throughout the country. Bring your questions and interact with NRP experts about science, administration, simulation, and educational methodology.

For those interested in some true crime sensationalistic documentary with a neonatology twist:

Clinical Focus

  • Neonatal-Perinatal Medicine

Academic Appointments

Administrative Appointments

  • Co-PI, Chief Medical Officer, California Perinatal Quality Care Collaborative (2017 - Present)

Boards, Advisory Committees, Professional Organizations

  • Associate Editor, CME, Neoreviews (2008 - Present)
  • Neonatal Delegation, International Liaison Committee on Resuscitation (2011 - Present)
  • Council, American Academy of Pediatrics Section on Neonatal-Perinatal Medicine District IX (2014 - Present)
  • Co-Chair, Neonatal Resuscitation Program (NRP) Steering Committee, American Academy of Pediatrics (2017 - Present)

Professional Education

  • Residency: Stanford University School of Medicine (2002) CA
  • Internship: Stanford University School of Medicine (2000) CA
  • Fellowship: Lucile Packard Children's Hospital (2007) CA
  • Medical Education: University of Illinois College of Medicine (1999) IL
  • Certificate, University of California San Francisco, Implementation Science (2010)
  • MS, Stanford University, Epidemiology (2006)
  • BS, Univ. of Illinois at Urbana, Electrical Engineering (1994)

Community and International Work

  • China NRP Task Force, China


    Neonatal resuscitation

    Partnering Organization(s)

    China Ministry of Health, AAP, Johnson & Johnson



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Perinatal and neonatal epidemiology.
Assessment of quality of care for mothers and newborns.
Quality improvement, dissemination, and implementation of evidence-based practices.
Simulation in neonatal resuscitation.
Benefits of breast milk for preterm infants.


2020-21 Courses

Stanford Advisees


All Publications

  • A Neonate With a Perineal Lesion. NeoReviews Eskandar-Afshari, F., Danzer, E., Lee, H. C., Ragavan, N. 2019; 20 (11): e680?e682

    View details for DOI 10.1542/neo.20-11-e680

    View details for PubMedID 31676744

  • Change in neonatal resuscitation guidelines and trends in incidence of meconium aspiration syndrome in California. Journal of perinatology : official journal of the California Perinatal Association Kalra, V. K., Lee, H. C., Sie, L., Ratnasiri, A. W., Underwood, M. A., Lakshminrusimha, S. 2019


    OBJECTIVE: To describe trends in the incidence and severity of meconium aspiration syndrome (MAS) around the release of revised Neonatal Resuscitation Program (NRP) guidelines in 2016.STUDY DESIGN: The California Perinatal Quality Care Collaborative database was queried for years 2013-2017 to describe the incidence and outcomes of infants with MAS. Results were analyzed based on both individual years and pre- vs. post-guideline epochs (2013-15 vs. 2017).RESULT: Incidence of MAS decreased significantly from 2013-15 to 2017 (1.02 to 0.78/1000 births, p<0.001). Among infants with MAS, delivery room intubations decreased from 2013-15 to 2017 (44.3 vs. 35.1%; p=0.005), but similar proportion of infants required invasive respiratory support (80.1 vs. 80.8%), inhaled nitric oxide (28.8 vs. 28.4%) or extracorporeal membrane oxygenation (0.81 vs. 0.35%).CONCLUSION: While the study design precludes confirmation of implementation of the recent NRP recommendation, there was no increase in the incidence or severity of MAS following its release.

    View details for DOI 10.1038/s41372-019-0529-0

    View details for PubMedID 31611615

  • Improved Referral of Very Low Birthweight Infants to High-Risk Infant Follow-Up in California. The Journal of pediatrics Pai, V. V., Kan, P., Bennett, M., Carmichael, S. L., Lee, H. C., Hintz, S. R. 2019


    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

  • Risk Factors for Maternal Readmission with Sepsis. American journal of perinatology Foeller, M. E., Sie, L., Foeller, T. M., Girsen, A. I., Carmichael, S. L., Lyell, D. J., Lee, H. C., Gibbs, R. S. 2019


    OBJECTIVE: Our primary objective was to identify risk factors for maternal readmission with sepsis. Our secondary objectives were to (1) assess diagnoses and infecting organisms at readmission and (2) compare early (<6 weeks) and late (6 weeks to 9 months postpartum) maternal readmission with sepsis.STUDY DESIGN: We identified our cohort using linked hospital discharge data and birth certificates for California deliveries from 2008 to 2011. Consistent with the 2016 sepsis classification, we defined sepsis as septicemia plus acute organ dysfunction. We compared women with early or late readmission with sepsis to women without readmission with sepsis.RESULTS: Among 1,880,264 women, 494 (0.03%) were readmitted with sepsis, 61% after 6 weeks. Risk factors for readmission with sepsis included preterm birth, hemorrhage, obesity, government-provided insurance, and primary cesarean. For both early and late sepsis readmissions, the most common diagnoses were urinary tract infection and pyelonephritis, and the most frequently identified infecting organism was gram-negative bacteria. Women with early compared with late readmission with sepsis shared similar obstetric characteristics.CONCLUSION: Maternal risk factors for both early and late readmission with sepsis included demographic characteristics, cesarean, hemorrhage, and preterm birth. Risks for sepsis after delivery persist beyond the traditional postpartum period of 6 weeks.

    View details for DOI 10.1055/s-0039-1696721

    View details for PubMedID 31529451

  • Low-Interventional Approaches to Intrapartum Care: Hospital Variation in Practice and Associated Factors. Journal of midwifery & women's health Lundsberg, L. S., Main, E. K., Lee, H. C., Lin, H., Illuzzi, J. L., Xu, X. 2019


    INTRODUCTION: Despite evidence supporting the safety of low-interventional approaches to intrapartum care, defined by the American College of Obstetricians and Gynecologists as "practices that facilitate a physiologic labor process and minimize intervention," little is known about how frequently such practices are utilized. We examined hospital use of low-interventional practices, as well as variation in utilization across hospitals.METHODS: Data came from 185 California hospitals completing a survey of intrapartum care, including 9 questions indicating use of low- versus high-interventional practices (eg, use of intermittent auscultation, nonpharmacologic pain relief, and admission of women in latent labor). We performed a group-based latent class analysis to identify distinct groups of hospitals exhibiting different levels of utilization on these 9 measures. Multivariable logistic regression identified institutional characteristics associated with a hospital's likelihood of using low-interventional practices. Procedure rates and patient outcomes were compared between the hospital groups using bivariate analysis.RESULTS: We identified 2 distinct groups of hospitals that tended to use low-interventional (n = 44, 23.8%) and high-interventional (n = 141, 76.2%) practices, respectively. Hospitals more likely to use low-interventional practices included those with midwife-led or physician-midwife collaborative labor management (adjusted odds ratio [aOR], 7.52; 95% CI, 2.53-22.37; P < .001) and those in rural locations (aOR, 3.73; 95% CI, 1.03-13.60; P = .04). Hospitals with a higher proportion of women covered by Medicaid or other safety-net programs were less likely to use low-interventional practices (aOR, 0.96; 95% CI, 0.93-0.99; P = .004), as were hospitals in counties with higher medical liability insurance premiums (aOR, 0.53; 95% CI, 0.33-0.85; P = .008). Hospitals in the low-intervention group had comparable rates of severe maternal and newborn morbidities but lower rates of cesarean birth and episiotomy compared with hospitals in the high-intervention group.DISCUSSION: Only one-quarter of hospitals used low-interventional practices. Attention to hospital culture of care, incorporating the midwifery model of care, and addressing medical-legal concerns may help promote utilization of low-interventional intrapartum practices.

    View details for DOI 10.1111/jmwh.13017

    View details for PubMedID 31502407

  • Rate and causes of severe maternal morbidity at readmission: California births in 2008-2012. Journal of perinatology : official journal of the California Perinatal Association Girsen, A. I., Sie, L., Carmichael, S. L., Lee, H. C., Foeller, M. E., Druzin, M. L., Gibbs, R. S. 2019


    OBJECTIVE: To determine the rate, maternal characteristics, timing, and indicators of severe maternal morbidity (SMM) that occurs at postpartum readmission.STUDY DESIGN: Women with a birth in California during 2008-2012 were included in the analysis. Readmissions up to 42 days after delivery were investigated. SMM was defined as presence of any of the 21 indicators defined by ICD-9 codes.RESULTS: Among 2,413,943 women with a birth, SMM at readmission occurred in 4229 women. Of all SMM, 12.1% occurred at readmission. Over half (53.5%) of the readmissions with SMM occurred within the first week after delivery hospitalization. The most common indicators of SMM were blood transfusion, sepsis, and pulmonary edema/acute heart failure.CONCLUSION: Twelve percent of SMM was identified at readmission with the majority occurring within 1 week after discharge from delivery hospitalization. Because early readmission may reflect lack of discharge readiness, there may be opportunities to improve care.

    View details for DOI 10.1038/s41372-019-0481-z

    View details for PubMedID 31462721

  • Factors Associated with Timeliness of Surgical Repair among Infants with Myelomeningocele: California Perinatal Quality Care Collaborative, 2006 to 2011. American journal of perinatology Kancherla, V., Ma, C., Grant, G., Lee, H. C., Shaw, G. M., Hintz, S. R., Carmichael, S. L. 2019


    OBJECTIVE: To examine factors associated with timely (0-2 days after birth) myelomeningocele surgical repair.STUDY DESIGN: We examined 2006 to 2011 births from the California Perinatal Quality Care Collaborative, linking to hospital discharge and vital records. Selected maternal, infant, and delivery hospital characteristics were evaluated to understand disparities in timely repair. Poisson regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs).RESULTS: Overall, 399 of the 450 (89%) infants had a timely repair and approximately 80% of them were delivered in level III/IV hospitals. Infants with hydrocephalus were significantly less likely to have a delayed myelomeningocele repair compared with those without (aRR=0.22; 95% CI=0.13, 0.39); infants whose medical care was paid by Medi-Cal or other nonprivate insurance were 2.2 times more likely to have a delayed repair compared with those covered by a private insurance (aRR=2.23; 95% CI=1.17, 4.27). Low birth weight was a significant predictor for delayed repair (aRR=2.06; 95% CI=1.10, 3.83).CONCLUSION: There was a significant disparity in myelomenigocele repair based on medical care payer. Families and hospitals should work together for timely repair in hospitals having specialized multidisciplinary teams. Findings from the study can be used to follow best clinical practices for myelomeningocele repair.

    View details for DOI 10.1055/s-0039-1693127

    View details for PubMedID 31307103

  • The disproportionate cost of operation and congenital anomalies ininfancy. Surgery Apfeld, J. C., Kastenberg, Z. J., Gibbons, A. T., Phibbs, C. S., Lee, H. C., Sylvester, K. G. 2019


    BACKGROUND: Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life.METHODS: Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system.RESULTS: In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n= 32,614) or had a diagnosis of a severe congenital anomaly (n= 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n= 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies.CONCLUSION: In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

    View details for PubMedID 31056199

  • Home Oxygen Use for Preterm Infants with Bronchopulmonary Dysplasia in California. The Journal of pediatrics Ejiawoko, A., Lee, H. C., Lu, T., Lagatta, J. 2019


    OBJECTIVES: To identify predictors of home oxygen use in preterm infants with bronchopulmonary dysplasia (BPD) in a statewide cohort, identify hospital variation in home oxygen use, and determine the relationship between home oxygen use and neonatal intensive care unit discharge timing.STUDY DESIGN: This was a secondary analysis of California Perinatal Quality Care Collaborative data. Infants were born <32weeks of gestation, diagnosed with BPD based on respiratory support at 36weeks postmenstrual age (PMA), and discharged home. Risk factors for home oxygen use were identified using a logistic mixed model with center as random effect. Estimates were used to calculate each center's observed to expected ratio of home oxygen use, and a Spearman coefficient between center median PMA at discharge and observed and expected proportions of home oxygen use.RESULTS: Of 7846, 3672 infants (47%) with BPD were discharged with home oxygen. Higher odds of home oxygen use were seen with antenatal steroids, maternal hypertension, earlier gestational age, male sex, ductus arteriosus ligation, more ventilator days, nitric oxide, discharge from regional hospitals, and PMA at discharge (receiver operating characteristic area under the curve 0.85). Of 92 hospitals, home oxygen use ranged from 7% to 95%; 42% of observed home oxygen use was significantly higher or lower than expected given patient characteristics. The 67 community hospitals with higher observed rates of home oxygen had earlier median PMA at discharge (correlation -0.27, P=.024).CONCLUSIONS: Clinical and hospital factors predict home oxygen use. Home oxygen use varies across California, with community centers using more home oxygen having a shorter length of stay.

    View details for PubMedID 30987778

  • Factors Associated with Successful First High-Risk Infant Clinic Visit for Very Low Birth Weight Infants in California. The Journal of pediatrics Hintz, S. R., Gould, J. B., Bennett, M. V., Lu, T., Gray, E. E., Jocson, M. A., Fuller, M. G., Lee, H. C. 2019


    OBJECTIVES: To determine rates of at least 1 high-risk infant follow-up (HRIF) visit by 12months corrected age, and factors associated with successful first visit among very low birth weight (VLBW) infants in a statewide population-based setting.STUDY DESIGN: We used the linked California Perinatal Quality of Care Collaborative and California Perinatal Quality of Care Collaborative-California Children's Services HRIF databases. Multivariable logistic regression examined independent associations of maternal, sociodemographic, neonatal clinical, and HRIF program factors with a successful first HRIF visit among VLBW infants born in 2010-2011.RESULTS: Among 6512 VLBW children referred to HRIF, 4938 (76%) attended a first visit. Higher odds for first HRIF visit attendance was associated with older maternal age (OR, 1.48; 95% CI, 1.27-1.72; 30-39 vs 20-29years), lower birth weight (OR, 2.11; 95% CI, 1.69-2.65; ?750g vs 1251-1499g), private insurance (OR, 1.65; 95% CI, 1.19-2.31), a history of severe intracranial hemorrhage (OR, 1.61; 95% CI, 1.12-2.30), 2 parents as primary caregivers (OR, 1.18, 95% CI 1.03-1.36), and higher HRIF program volume (OR, 2.62; 95% CI, 1.88-3.66; second vs lowest quartile); and lower odds with maternal race African American or black (OR, 0.65; 95% CI, 0.54-0.78), and greater distance to HRIF program (OR, 0.69; 95% CI, 0.57-0.83). Rates varied substantially across HRIF programs, which remained after risk adjustment.CONCLUSIONS: In a population-based California VLBW cohort, maternal, sociodemographic, and home- and program-level disparities were associated with HRIF non-attendance. These findings underscore the need to identify challenges in access and resource risk factors during hospitalization in the neonatal intensive care unit, provide enhanced education about the benefits of HRIF, and create comprehensive neonatal intensive care unit-to-home transition approaches.

    View details for PubMedID 30967249

  • Racial Segregation and Inequality in the Neonatal Intensive Care Unit for Very Low-Birth-Weight and Very Preterm Infants. JAMA pediatrics Horbar, J. D., Edwards, E. M., Greenberg, L. T., Profit, J., Draper, D., Helkey, D., Lorch, S. A., Lee, H. C., Phibbs, C. S., Rogowski, J., Gould, J. B., Firebaugh, G. 2019


    Importance: Racial and ethnic minorities receive lower-quality health care than white non-Hispanic individuals in the United States. Where minority infants receive care and the role that may play in the quality of care received is unclear.Objective: To determine the extent of segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States.Design, Setting, and Participants: This cohort study of 743 NICUs in the Vermont Oxford Network included 117?982 black, Hispanic, Asian, and white infants born at 401 g to 1500 g or 22 to 29 weeks' gestation from January 2014 to December 2016. Analysis began January 2018.Main Outcomes and Measures: The NICU segregation index and NICU inequality index were calculated at the hospital level as the Gini coefficients associated with the Lorenz curves for black, Hispanic, and Asian infants compared with white infants, with NICUs ranked by proportion of white infants for the NICU segregation index and by composite Baby-MONITOR (Measure of Neonatal Intensive Care Outcomes Research) score for the NICU inequality index.Results: Infants (36?359 black [31%], 21?808 Hispanic [18%], 5920 Asian [5%], and 53?895 white [46%]) were segregated among the 743 NICUs by race and ethnicity (NICU segregation index: black: 0.50 [95% CI, 0.46-0.53], Hispanic: 0.58 [95% CI, 0.54-0.61], and Asian: 0.45 [95% CI, 0.40-0.50]). Compared with white infants, black infants were concentrated at NICUs with lower-quality scores, and Hispanic and Asian infants were concentrated at NICUs with higher-quality scores (NICU inequality index: black: 0.07 [95% CI, 0.02-0.13], Hispanic: -0.10 [95% CI, -0.17 to -0.04], and Asian: -0.26 [95% CI, -0.32 to -0.19]). There was marked variation among the census regions in weighted mean NICU quality scores (range: -0.69 to 0.85). Region of residence explained the observed inequality for Hispanic infants but not for black or Asian infants.Conclusions and Relevance: Black, Hispanic, and Asian infants were segregated across NICUs, reflecting the racial segregation of minority populations in the United States. There were large differences between geographic regions in NICU quality. After accounting for these differences, compared with white infants, Asian infants received care at higher-quality NICUs and black infants, at lower-quality NICUs. Explaining these patterns will require understanding the effects of sociodemographic factors and public policies on hospital quality, access, and choice for minority women and their infants.

    View details for PubMedID 30907924

  • Delayed Cord Clamping and Umbilical Cord Milking among Infants in California Neonatal Intensive Care Units. American journal of perinatology Tran, C. L., Parucha, J. M., Jegatheesan, P., Lee, H. C. 2019


    OBJECTIVE: To assess the current practice of delayed cord clamping (DCC) and to determine patient and hospital factors that predict DCC.STUDY DESIGN: The California Perinatal Quality Care Collaborative (CPQCC) collects data on preterm and acutely ill infants. In 2016, 52 CPQCC neonatal intensive care units (NICUs) collected data on DCC. Hospital and patient characteristics were analyzed using multivariable logistic regression.RESULTS: Of 5,332 deliveries, 1,555 (29%) newborns received DCC. Hospital rates ranged from 0 to 74.5% and increased from 21 to 37% throughout 2016. Infants delivered at <32 weeks or with birth weight <1,500g were more likely to receive DCC (odds ratio: 2.80; 95% confidence interval: 2.33, 3.36). Cesarean delivery was associated with less likelihood of DCC (odds ratio: 0.68; 95% confidence interval: 0.59, 0.79). After risk adjustment, 17 (33%) hospitals had higher than expected DCC rate. Hospitals with less than 50 NICU beds are more likely to practice DCC, whereas Level 3 American Academy of Pediatrics NICUs, nonprofit owned hospitals, and teaching institutions were less likely to practice DCC (p<0.001).CONCLUSION: There are opportunities to implement quality improvement activities to increase DCC rates.

    View details for PubMedID 30900218

  • Cytomegalovirus Infection among Infants in Neonatal Intensive Care Units, California, 2005 to 2016. American journal of perinatology Tran, C., Bennett, M. V., Gould, J. B., Lee, H. C., Lanzieri, T. M. 2019


    AIM: The main purpose of this article is to assess trends in cytomegalovirus (CMV) infection reported among infants in California neonatal intensive care units (NICUs) during 2005 to 2016.STUDY DESIGN: The California Perinatal Quality Care Collaborative collects data on all very low birth weight (VLBW, birth weight ? 1,500 g) and acutely ill infants>1,500g, representing 92% of NICUs in California. We compared clinical characteristics and length of hospital stay among infants with and without reported CMV infection (CMV-positive viral culture or polymerase chain reaction).RESULTS: During 2005 to 2016, CMV infection was reported in 174 VLBW infants and 145 infants>1,500g, or 2.7 (range: 1.5-4.7) and 1.2 (range: 0.8-1.7) per 1,000 infants, respectively (no significant annual trend). Among infants>1,500g, 12 (8%) versus 4,928 (4%) of those reported with versus without CMV infection died (p<0.05). The median hospital stay was significantly longer among infants reported with versus without CMV infection for both VLBW infants (98 vs. 46 days) and infants>1,500g (61 vs. 14 days) (p<0.001).CONCLUSION: Reports of CMV infection remained stable over a 12-year period. Although we were not able to assess whether infection was congenital or postnatal, CMV infection among infants>1,500g was associated with increased mortality.

    View details for PubMedID 30895580

  • Maternal and Infant Adverse Outcomes Associated with Mild and Severe Preeclampsia during the First Year after Delivery in the United States. American journal of perinatology Ton, T. G., Bennett, M. V., Incerti, D., Peneva, D., Druzin, M., Stevens, W., Butwick, A. J., Lee, H. C. 2019


    BACKGROUND: The burden of preeclampsia severity on the health of mothers and infants during the first year after delivery is unclear given the lack of population-based longitudinal studies in the United States.METHODS: We assessed maternal and infant adverse outcomes during the first year after delivery using population-based hospital discharge information merged with vital statistics and birth certificates of 2,021,013 linked maternal-infant births in California. We calculated sampling weights using the National Center for Health Statistics data to adjust for observed differences in maternal characteristics between California and the rest of the United States. Separately, we estimated the association between preeclampsia and gestational age and examined collider bias in models of preeclampsia and maternal and infant adverse outcomes.RESULTS: Compared with women without preeclampsia, women with mild and severe preeclampsia delivered 0.66 weeks (95% confidence interval [CI]: 0.64, 0.68) and 2.74 weeks (95% CI: 2.72, 2.77) earlier, respectively. Mild preeclampsia was associated with an increased risk of having any maternal adverse outcome (relative risk [RR]=1.95; 95% CI: 1.93, 1.97), as was severe preeclampsia (RR=2.80; 95% CI: 2.78, 2.82). The risk of an infant adverse outcome was increased for severe preeclampsia (RR=2.15; 95% CI: 2.14, 2.17) but only marginally for mild preeclampsia (RR=0.99; 95% CI: 0.98, 1). Collider bias produced an inverse association for mild preeclampsia and attenuated the association for severe preeclampsia in models for any infant adverse outcome.CONCLUSION: Using multiple datasets, we estimated that severe preeclampsia is associated with a higher risk of maternal and infant adverse outcomes compared with mild preeclampsia, including an earlier preterm delivery.

    View details for PubMedID 30780187

  • Clinical deterioration during neonatal transport in California. Journal of perinatology : official journal of the California Perinatal Association Pai, V. V., Kan, P. n., Gould, J. B., Hackel, A. n., Lee, H. C. 2019


    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

  • Trends in maternal prepregnancy body mass index (BMI) and its association with birth and maternal outcomes in California, 2007-2016: A retrospective cohort study. PloS one Ratnasiri, A. W., Lee, H. C., Lakshminrusimha, S. n., Parry, S. S., Arief, V. N., DeLacy, I. H., Yang, J. S., DiLibero, R. J., Logan, J. n., Basford, K. E. 2019; 14 (9): e0222458


    To determine recent trends in maternal prepregnancy body mass index (BMI) and to quantify its association with birth and maternal outcomes.A population-based retrospective cohort study included resident women with singleton births in the California Birth Statistical Master Files (BSMF) database from 2007 to 2016. There were 4,621,082 women included out of 5,054,968 women registered in the database. 433,886 (8.6%) women were excluded due to invalid or missing information for BMI. Exposures were underweight (BMI < 18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (? 30 kg/m2) at the onset of pregnancy. Obesity was subcategorized into class I (30.0-34.9 kg/m2), class II (35.0-39.9 kg/m2), and class III (? 40 kg/m2), while adverse outcomes examined were low birth weight (LBW), very low birth weight (VLBW), macrosomic births, preterm birth (PTB), very preterm birth (VPTB), small-for-gestational-age birth (SGA), large-for-gestational-age birth (LGA), and cesarean delivery (CD). Descriptive analysis, simple linear regression, and multivariate logistic regression were performed, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) for associations were estimated.Over the ten-year study period, the prevalence of underweight and normal weight women at time of birth declined by 10.6% and 9.7%, respectively, while the prevalence of overweight and obese increased by 4.3% and 22.9%, respectively. VLBW increased significantly with increasing BMI, by 24% in overweight women and by 76% in women with class III obesity from 2007 to 2016. Women with class III obesity also had a significant increase in macrosomic birth (170%) and were more likely to deliver PTB (33%), VPTB (66%), LGA (231%), and CD (208%) than women with a normal BMI. However, obese women were less likely to have SGA infants; underweight women were 51% more likely to have SGA infants than women with a normal BMI.In California from 2007 to 2016, there was a declining trend in women with prepregnancy normal weight, and a rising trend in overweight and obese women, particularly obesity class III. Both extremes of prepregnancy BMI were associated with an increased incidence of adverse neonatal outcomes; however, the worse outcomes were prominent in those women classified as obese.

    View details for DOI 10.1371/journal.pone.0222458

    View details for PubMedID 31536528

  • Hospitalization costs associated with bronchopulmonary dysplasia in the first year of life. Journal of perinatology : official journal of the California Perinatal Association Lapcharoensap, W. n., Bennett, M. V., Xu, X. n., Lee, H. C., Dukhovny, D. n. 2019


    To determine costs of hospitalization associated with bronchopulmonary dysplasia (BPD) during the first year in very low birth weight infants.Retrospective cohort study of California births from 2008 to 2011 linking birth certificate, discharge records, and clinical data from California Perinatal Quality Care Collaborative. Inclusion: birth weight 401-1500?g, gestational age?

    View details for DOI 10.1038/s41372-019-0548-x

    View details for PubMedID 31700090

  • Disparities in Health Care-Associated Infections in the NICU. American journal of perinatology Liu, J. n., Sakarovitch, C. n., Sigurdson, K. n., Lee, H. C., Profit, J. n. 2019


    ?This study aimed to examine multilevel risk factors for health care-associated infection (HAI) among very low birth weight (VLBW) infants with a focus on race/ethnicity and its association with variation in infection across hospitals.?This is a population-based cohort study of 20,692 VLBW infants born between 2011 and 2015 in the California Perinatal Quality Care Collaborative.?Risk-adjusted infection rates varied widely across neonatal intensive care units (NICUs), ranging from 0 to 24.6% across 5 years. Although Hispanic infants had higher odds of HAI overall, race/ethnicity did not affect the variation in infection rates. Non-Hispanic black mothers were more likely to receive care in NICUs within the top tertile of infection risk. Yet, among NICUs in this tertile, infants across all races and ethnicities suffered similar high rates of infection.?Hispanic infants had higher odds of infection. We found significant variation in infection across NICUs, even after accounting for factors usually associated with infection.

    View details for PubMedID 31039596

  • Prenatal and postnatal inflammation-related risk factors for retinopathy of prematurity. Journal of perinatology : official journal of the California Perinatal Association Goldstein, G. P., Leonard, S. A., Kan, P. n., Koo, E. B., Lee, H. C., Carmichael, S. L. 2019


    To evaluate the relationship between prenatal and postnatal inflammation-related risk factors and severe retinopathy of prematurity (ROP).The study included infants born <30 weeks in California from 2007 to 2011. Multivariable log-binomial regression was used to assess the association between prenatal and postnatal inflammation-related exposures and severe ROP, defined as stage 3-5 or surgery for ROP.Of 14,816 infants, 10.8% developed severe ROP. Though prenatal inflammation-related risk factors were initially associated with severe ROP, after accounting for the effect of these risk factors on gestational age at birth through mediation analysis, the association was non-significant (P?=?0.6). Postnatal factors associated with severe ROP included prolonged oxygen exposure, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis.Postnatal inflammation-related factors were associated with severe ROP more strongly than prenatal factors. The association between prenatal inflammation-related factors and ROP was explained by earlier gestational age in infants exposed to prenatal inflammation.

    View details for PubMedID 30932029

  • "Following through": addressing the racial inequality for preterm infants and their families. Pediatric research Stevenson, D. K., Wong, R. J., Profit, J. n., Shaw, G. M., Jason Wang, C. n., Lee, H. C. 2019

    View details for DOI 10.1038/s41390-019-0602-6

    View details for PubMedID 31581171

  • Understanding the Heterogeneity of Labor and Delivery Units: Using Design Thinking Methodology to Assess Environmental Factors that Contribute to Safety in Childbirth. American journal of perinatology Sherman, J. P., Hedli, L. C., Kristensen-Cabrera, A. I., Lipman, S. S., Schwandt, D. n., Lee, H. C., Sie, L. n., Halamek, L. P., Austin, N. S. 2019


    ?There is limited research exploring the relationship between design and patient safety outcomes, especially in maternal and neonatal care. We employed design thinking methodology to understand how the design of labor and delivery units impacts safety and identified spaces and systems where improvements are needed.?Site visits were conducted at 10 labor and delivery units in California. A multidisciplinary team collected data through observations, measurements, and clinician interviews. In parallel, research was conducted regarding current standards and codes for building new hospitals.?Designs of labor and delivery units are heterogeneous, lacking in consistency regarding environmental factors that may impact safety and outcomes. Building codes do not take into consideration workflow, human factors, and patient and clinician experience. Attitude of hospital staff may contribute to improving safety through design. Three areas in need of improvement and actionable through design emerged: (1) blood availability for hemorrhage management, (2) appropriate space for neonatal resuscitation, and (3) restocking and organization methods of equipment and supplies.?Design thinking could be implemented at various stages of health care facility building projects and during retrofits of existing units. Through this approach, we may be able to improve hospital systems and environmental factors.

    View details for PubMedID 31013540

  • Safety and Ergonomic Challenges of Ventilating a Premature Infant During Delayed Cord Clamping. Children (Basel, Switzerland) Lapcharoensap, W. n., Cong, A. n., Sherman, J. n., Schwandt, D. n., Crowe, S. n., Daniels, K. n., Lee, H. C. 2019; 6 (4)


    Delayed cord clamping (DCC) is endorsed by multiple professional organizations for both term and preterm infants. In preterm infants, DCC has been shown to reduce intraventricular hemorrhage, lower incidence of necrotizing enterocolitis, and reduce the need for transfusions. Furthermore, in preterm animal models, ventilation during DCC leads to improved hemodynamics. While providing ventilation and continuous positive airway pressure (CPAP) during DCC may benefit infants, the logistics of performing such a maneuver can be complicated. In this simulation-based study, we sought to explore attitudes of providers along with the safety and ergonomic challenges involved with safely resuscitating a newborn infant while attached to the placenta. Multidisciplinary workshops were held simulating vaginal and Caesarean deliveries, during which providers started positive pressure ventilation and transitioned to holding CPAP on a preterm manikin. Review of videos identified 5 themes of concerns: sterility, equipment, mobility, space and workflow, and communication. In this study, simulation was a key methodology for safe identification of various safety and ergonomic issues related to implementation of ventilation during DCC. Centers interested in implementing DCC with ventilation are encouraged to form multidisciplinary work groups and utilize simulations prior to performing care on infants.

    View details for PubMedID 31013884

  • A population-based study to identify the prevalence and correlates of the dual burden of severe maternal morbidity and preterm birth in California. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians Lyndon, A. n., Baer, R. J., Gay, C. L., El Ayadi, A. M., Lee, H. C., Jelliffe-Pawlowski, L. n. 2019: 1?391


    Background: Prior studies have documented associations between preterm birth and severe maternal morbidity but the prevalence and correlates of dual burden are not adequately understood, despite significant family implications. Purpose: To describe the prevalence and correlates of the dual burden of SMM and preterm birth and to understand profiles of SMM by dual burden of preterm birth. Approach: This retrospective cohort study included all California live births in 2007-2012 with gestations 20-44 weeks and linked to a birth cohort database maintained by the California Office of Statewide Health Planning and Development (n = 3 059 156). Dual burden was defined as preterm birth (< 37 weeks) with severe maternal morbidity (SMM, defined by Centers for Disease Control). Predictors for dual burden were assessed using Poisson logistic regression, accounting for hospital variance. Results: Rates of preterm birth and SMM were 876 and 140 per 10 000 births, respectively. The most common indications of SMM both with and without preterm birth were blood transfusions and a combination of cardiac indications. One-quarter of women with SMM experienced preterm birth; with a dual burden rate of 37 per 10 000 births. Risk of dual burden was over three-fold higher with cesarean birth (primiparous primary aRR = 3.3, CI 3.0,3.6; multiparous primary aRR = 8.1, CI 7.2,9.1; repeat aRR = 3.9, CI 3.5,4.3). Multiple gestation conferred a six-fold increased risk (aRR = 6.3, CI 5.8,6.9). Women with preeclampsia superimposed on gestational hypertension (aRR = 7.3, CI 6.8,7.9) or preexisting hypertension (aRR = 11.1, CI 9.9,12.5) had significantly higher dual burden risk. Significant independent predictors for dual burden included smoking during pregnancy (aRR = 1.5, CI 1.4,1.7), preexisting hypertension without preeclampsia (aRR = 3.3, CI 3.0,3.7), preexisting diabetes (aRR = 2.6, CI 2.3,3.0), Black race/ethnicity (aRR = 2.0, CI 1.8,2.2), and prepregnancy body mass index < 18.5 (aRR = 1.4, CI 1.3,1.5). Conclusions: Dual burden affects 1900 California families annually. The strongest predictors of dual burden were hypertensive disorders with preeclampsia and multiparous primary cesarean.

    View details for DOI 10.1080/14767058.2019.1628941

    View details for PubMedID 31170837

  • Neonatal transport in California: findings from a qualitative investigation. Journal of perinatology : official journal of the California Perinatal Association Akula, V. P., Hedli, L. C., Van Meurs, K. n., Gould, J. B., Peiyi, K. n., Lee, H. C. 2019


    To identify characteristics of neonatal transport in California and which factors influence team performance.We led focus group discussions with 19 transport teams operating in California, interviewing 158 neonatal transport team members. Transcripts were analyzed using a thematic analysis approach.The composition of transport teams varied widely. There was strong thematic resonance to suggest that the nature of emergent neonatal transports is unpredictable and poses several significant challenges including staffing, ambulance availability, and administrative support. Teams reported dealing with this unpredictability by engaging in teamwork, gathering experience with staff at referral hospitals, planning for a wide variety of circumstances, specialized training, debriefing after events, and implementing quality improvement strategies.Our findings suggest potential opportunities for improvement in neonatal transport. Future research can explore the cost and benefits of strategies such as dedicated transport services, transfer centers, and telemedicine.

    View details for DOI 10.1038/s41372-019-0409-7

    View details for PubMedID 31270432

  • Smoking during Pregnancy and Adverse Birth and Maternal Outcomes in California, 2007 to 2016. American journal of perinatology Ratnasiri, A. W., Gordon, L. n., Dieckmann, R. A., Lee, H. C., Parry, S. S., Arief, V. N., DeLacy, I. H., Lakshminrusimha, S. n., DiLibero, R. J., Basford, K. E. 2019


    ?To determine associations between maternal cigarette smoking and adverse birth and maternal outcomes.?This is a 10-year population-based retrospective cohort study including 4,971,896 resident births in California. Pregnancy outcomes of maternal smokers were compared with those of nonsmokers. The outcomes of women who stopped smoking before or during various stages of pregnancy were also investigated.?Infants of women who smoked during pregnancy were twice as likely to have low birth weight (LBW) and be small for gestational age (SGA), 57% more likely to have very LBW (VLBW) or be a preterm birth (PTB), and 59% more likely to have a very PTB compared with infants of nonsmokers. During the study period, a significant widening of gaps developed in both rates of LBW and PTB and the percentage of SGA between infants of maternal smokers and nonsmokers.?Smoking during pregnancy is associated with a significantly increased risk of adverse birth and maternal outcomes, and differences in rates of LBW, PTB, and SGA between infants of maternal smokers and nonsmokers increased during this period. Stopping smoking before pregnancy or even during the first trimester significantly decreased the infant risks of LBW, PTB, SGA, and the maternal risk for cesarean delivery.

    View details for DOI 10.1055/s-0039-1693689

    View details for PubMedID 31365931

  • Newborn Antibiotic Exposures and Association With Proven Bloodstream Infection. Pediatrics Schulman, J. n., Benitz, W. E., Profit, J. n., Lee, H. C., Dueñas, G. n., Bennett, M. V., Jocson, M. A., Schutzengel, R. n., Gould, J. B. 2019


    To estimate the percentage of hospital births receiving antibiotics before being discharged from the hospital and efficiency diagnosing proven bloodstream infection.We conducted a cross-sectional study of 326?845 live births in 2017, with a 69% sample of all California births involving 121 California hospitals with a NICU, of which 116 routinely served inborn neonates. Exposure included intravenous or intramuscular antibiotic administered anywhere in the hospital during inpatient stay associated with maternal delivery. The main outcomes were the percent of newborns with antibiotic exposure and counts of exposed newborns per proven bloodstream infection. Units of observation and analysis were the individual hospitals. Correlation analyses included infection rates, surgical case volume, NICU inborn admission rates, and mortality rates.The percent of newborns with antibiotic exposure varied from 1.6% to 42.5% (mean 8.5%; SD 6.3%; median 7.3%). Across hospitals, 11.4 to 335.7 infants received antibiotics per proven early-onset sepsis case (mean 95.1; SD 71.1; median 69.5), and 2 to 164 infants received antibiotics per proven late-onset sepsis case (mean 19.6; SD 24.0; median 12.2). The percent of newborns with antibiotic exposure correlated neither with proven bloodstream infection nor with the percent of patient-days entailing antibiotic exposure.The percent of newborns with antibiotic exposure varies widely and is unexplained by proven bloodstream infection. Identification of sepsis, particularly early onset, often is extremely inefficient. Knowledge of the numbers of newborns receiving antibiotics complements evaluations anchored in days of exposure because these are uncorrelated measures.

    View details for DOI 10.1542/peds.2019-1105

    View details for PubMedID 31641017

  • Safety climate, safety climate strength, and length of stay in the NICU. BMC health services research Tawfik, D. S., Thomas, E. J., Vogus, T. J., Liu, J. B., Sharek, P. J., Nisbet, C. C., Lee, H. C., Sexton, J. B., Profit, J. n. 2019; 19 (1): 738


    Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU's respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (

    View details for DOI 10.1186/s12913-019-4592-1

    View details for PubMedID 31640679

  • Racial/Ethnic Disparities in Neonatal Intensive Care: A Systematic Review. Pediatrics Sigurdson, K. n., Mitchell, B. n., Liu, J. n., Morton, C. n., Gould, J. B., Lee, H. C., Capdarest-Arest, N. n., Profit, J. n. 2019


    Racial and ethnic disparities in health outcomes of newborns requiring care in the NICU setting have been reported. The contribution of NICU care to disparities in outcomes is unclear.To conduct a systematic review of the literature documenting racial/ethnic disparities in quality of care for infants in the NICU setting.Medline/PubMed, Scopus, Cumulative Index of Nursing and Allied Health, and Web of Science were searched until March 6, 2018, by using search queries organized around the following key concepts: "neonatal intensive care units," "racial or ethnic disparities," and "quality of care."English language articles up to March 6, 2018, that were focused on racial and/or ethnic differences in the quality of NICU care were selected.Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities.Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included.Quantitative meta-analysis was not possible because of study heterogeneity.Overall, this systematic review revealed complex racial and/or ethnic disparities in structure, process, and outcome measures, most often disadvantaging infants of color, especially African American infants. There are some exceptions to this pattern and each area merits its own analysis and discussion.

    View details for DOI 10.1542/peds.2018-3114

    View details for PubMedID 31358664

  • Survey of preterm neuro-centric care practices in California neonatal intensive care units. Journal of perinatology : official journal of the California Perinatal Association Handley, S. C., Passarella, M., Lorch, S. A., Lee, H. C. 2018


    OBJECTIVE: Examine the adoption and presence of preterm, neuro-centric care practices across neonatal intensive care units (NICUs).STUDY DESIGN: Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives.RESULT: Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold, whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice.CONCLUSION: Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.

    View details for PubMedID 30518797

  • Birth Location of Infants with Critical Congenital Heart Disease in California. Pediatric cardiology Purkey, N. J., Axelrod, D. M., McElhinney, D. B., Rigdon, J., Qin, F., Desai, M., Shin, A. Y., Chock, V. Y., Lee, H. C. 2018


    The American Academy of Pediatrics classifies neonatal intensive care units (NICUs) from level I to IV based on the acuity of care each unit can provide. Birth in a higher level center is associated with lower morbidity and mortality in high-risk populations. Congenital heart disease accounts for 25-50% of infant mortality related to birth defects in the U.S., but recent data are lacking on where infants with critical congenital heart disease (CCHD) are born. We used a linked dataset from the Office of Statewide Health Planning and Development to access ICD-9 diagnosis codes for all infants born in California from 2008 to 2012. We compared infants with CCHD to the general population, identified where infants with CCHD were born based on NICU level of care, and predicted level IV birth among infants with CCHD using logistic regression techniques. From 2008 to 2012, 6325 infants with CCHD were born in California, with 23.7% of infants with CCHD born at a level IV NICU compared to 8.4% of the general population. Level IV birth for infants with CCHD was associated with lower gestational age, higher maternal age and education, the presence of other congenital anomalies, and the diagnosis of a single ventricle lesion. More infants with CCHD are born in a level IV NICU compared to the general population. Future studies are needed to determine if birth in a lower level of care center impacts outcomes for infants with CCHD.

    View details for PubMedID 30415381

  • The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. Journal of patient safety Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. B. 2018


    OBJECTIVES: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.STUDY DESIGN: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions.RESULTS: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate.CONCLUSIONS: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    View details for PubMedID 30407963

  • Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011. The Journal of pediatrics Phibbs, C. S., Schmitt, S. K., Cooper, M., Gould, J. B., Lee, H. C., Profit, J., Lorch, S. A. 2018


    OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

    View details for PubMedID 30297293

  • Hospital Variation in Utilization and Success of Trial of Labor after A Prior Cesarean. American journal of obstetrics and gynecology Xu, X., Lee, H. C., Lin, H., Lundsberg, L. S., Campbell, K. H., Lipkind, H. S., Pettker, C. M., Illuzzi, J. L. 2018


    BACKGROUND: Trial of labor after cesarean delivery (TOLAC) is an effective and safe option for women without contraindications.OBJECTIVES: To examine hospital variation in utilization and success of TOLAC and identify associated institutional characteristics and patient outcomes.STUDY DESIGN: Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with one prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized rates of TOLAC utilization and success were estimated for each hospital after accounting for differences in patient case-mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of TOLAC and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' TOLAC utilization and success rates.RESULTS: In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, rate of TOLAC use and success varied considerably across hospitals with a median of 35.2% (10th-to-90th percentile range: 10.2-67.1%) and 40.5% (10th-to-90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of TOLAC demonstrated an inverted U-shaped relationship such that low or excessively high TOLAC use was associated with lower success rate. Compared to other births, those delivered at hospitals with above-the-median TOLAC use and success rates had a higher risk for uterine rupture (adjusted risk ratio [aRR] = 2.74, p<0.001), severe newborn respiratory complications (aRR=1.46, p<0.001), and severe newborn neurological complications/trauma (aRR=2.48, p<0.001), but they had a lower risk for severe newborn infection (aRR=0.80, p=0.003) and overall severe unexpected newborn complications (aRR=0.86, p<0.001), as well as shorter length of stays (adjusted mean ratio = 0.948 for mothers and 0.924 for newborns, p<0.001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of TOLAC. However, rural location and higher local malpractice insurance premium was negatively associated with TOLAC utilization, whereas for-profit ownership was associated with lower success rate.CONCLUSIONS: Utilization and success rates of TOLAC varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (e.g., increase availability at low TOLAC rate hospitals while being more selective at high TOLAC rate hospitals, and targeted support for lower capacity hospitals).

    View details for PubMedID 30278176

  • Covariation of Neonatal Intensive Care Unit-Level Patent Ductus Arteriosus Management and In-Neonatal Intensive Care Unit Outcomes Following Preterm Birth. The Journal of pediatrics Hagadorn, J. I., Bennett, M. V., Brownell, E. A., Payton, K. S., Benitz, W. E., Lee, H. C. 2018


    OBJECTIVE: To test the hypothesis that neonatal intensive care unit (NICU)-specific changes in patent ductus arteriosus (PDA) management are associated with changes in local outcomes in preterm infants.STUDY DESIGN: This retrospective repeated-measures study of aggregated data included infants born 400-1499g admitted within 2 days of delivery to NICUs participating in the California Perinatal Quality Care Collaborative. The period 2008-2015 was divided into four 2-year epochs. For each epoch and NICU, we calculated proportions of infants receiving cyclooxygenase inhibitor (COXI) or PDA ligation and determined NICU-specific changes in these therapies between consecutive epochs. Generalized estimating equations were used to examine adjusted relationships between NICU-specific changes in PDA management and contemporaneous changes in local outcomes.RESULTS: We included 642 observations of interepoch change at 119 hospitals summarizing 32 094 infants. NICU-specific changes in COXI use and ligation showed significant dose-response associations with contemporaneous changes in adjusted local outcomes. Each percentage point decrease in NICU-specific proportion treated with either COXI or ligation was associated with a 0.21 percentage point contemporaneous increase in adjusted local in-hospital mortality (95% CI 0.06, 0.33; P=.005) among infants born 400-749g. In contrast, decreasing NICU-specific ligation rate among infants 1000-1499g was associated with decreasing adjusted local bronchopulmonary dysplasia (P=.009) and death or bronchopulmonary dysplasia (P=.01).CONCLUSIONS: NICU-specific outcomes of preterm birth co-vary with local PDA management. Treatment for PDA closure may benefit some infants born 400-749g. Decreasing NICU-specific rates of COXI use or ligation were not associated with increases in local adjusted rates of examined adverse outcomes in larger preterm infants.

    View details for PubMedID 30243544

  • Variations in Neonatal Antibiotic Use PEDIATRICS Schulman, J., Profit, J., Lee, H. C., Duenas, G., Bennett, M. V., Parucha, J., Jocson, M. L., Gould, J. B. 2018; 142 (3)


    We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens.In a retrospective cohort study of >54?000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts.By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42?960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (? = 0.53; P = .01), mortality rate (? = 0.57; P = .004), and average length of stay (? = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%).Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

    View details for PubMedID 30177514

  • Transcutaneous bilirubinometer use and practices surrounding jaundice in 150 California newborn intensive care units. Journal of perinatology : official journal of the California Perinatal Association Bhatt, D. R., Kristensen-Cabrera, A. I., Lee, H. C., Weerasinghe, S., Stevenson, D. K., Bhutani, V. K., Maisels, M. J., Ramanathan, R. 2018


    OBJECTIVES: Transcutaneous bilirubin measurements (TcBs) provide a noninvasive method for screening infants for hyperbilirubinemia and have been used extensively in term and late preterm newborns in well baby nurseries, offices, and outpatient clinics. Several studies have also demonstrated the utility of TcBs as a screening tool for infants >28 weeks' gestation and their ability to reduce the need for blood sampling. The objectives of this study are to identify how often TcBs are used among California Newborn Intensive Care Units (NICUs) in preterm, late preterm and term infants, and other aspects of jaundice management.METHODS: We conducted a survey on TcB use and practices relating to jaundice management in 150 California NICUs between April and October 2016.RESULTS: TcB screening is routinely used in 28% (42/150) of NICUs. Only 7% (11/150) of NICUs use TcB in preterm infants <28 weeks. Practice varied similarly across NICU levels of care. Among the subset of NICUs that responded to questions related to phototherapy and screening practices, prophylactic phototherapy was used in 38% (23/59) and 90% (55/61) screened for glucose-6-phosphate dehydrogenase deficiency based on race, ethnicity, and/or family history.CONCLUSION(S): Despite studies validating the accuracy of TcB in preterm infants >28 weeks, only 28% of California NICUs routinely use TcB devices. TcB screening in infants <28 weeks gestation is not widely used and no recommendation can be made in this regard until there is more experience with its application using a standardized protocol in these infants and on a large scale.

    View details for PubMedID 30120424

  • Gaining Perspectives on Patient and Family Disease Experiences by Storytelling ACADEMIC PEDIATRICS Chandrasekar, H., Harte, S., Sherman, J., Park, K. T., Lee, H. C. 2018; 18 (4): 475?76
  • Maternal body mass index and risk of intraventricular hemorrhage in preterm infants. Pediatric research Pai, V. V., Carmichael, S. L., Kan, P., Leonard, S. A., Lee, H. C. 2018


    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

  • Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units. American journal of ophthalmology Eneriz-Wiemer, M., Liu, S., Chu, M. C., Uribe-Leitz, T., Rajani, K., Sankar, M., Robbins, S. L., Lee, H. C., Woodard, C., Wang, C. J. 2018


    PURPOSE: Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP.DESIGN: Cross-sectional study.METHODS: SETTING: Four high-acuity neonatal intensive care units in California (40-84 beds).PARTICIPANTS: 194 English- and Spanish-speaking parents of very low birth weight (<1,500 grams) infants recruited from September 2013 to April 2015.MAIN OUTCOME MEASURES: We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status.RESULTS: 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) and/or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (versus English-proficient, literate).CONCLUSIONS: Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.

    View details for PubMedID 29621506

  • A directory for neonatal intensive care: potential for facilitating network-based research in neonatology. Journal of perinatology : official journal of the California Perinatal Association Ariagno, R. L., Lee, H. C., Stevenson, D. K., Benjamin, D. K., Smith, P. B., Escobedo, M. B., Bhatt, D. R. 2018


    Directories of contact information have evolved over time from thick paperback times such as the "Yellow Pages" to electronic forms that are searchable and have other functionalities. In our clinical specialty, the development of a professional directory helped to promote collaboration in clinical care, education, and quality improvement. However, there are opportunities for increasing the utility of the directory by taking advantage of modern web-based tools, and expanding the use of the directory to fill a gap in the area of collaborative research.

    View details for DOI 10.1038/s41372-018-0097-8

    View details for PubMedID 29545621

  • Effect of Maternal Body Mass Index on Postpartum Hemorrhage. Anesthesiology Butwick, A. J., Abreo, A. n., Bateman, B. T., Lee, H. C., El-Sayed, Y. Y., Stephansson, O. n., Flood, P. n. 2018


    It is unclear whether obesity is a risk factor for postpartum hemorrhage. The authors hypothesized that obese women are at greater risk of hemorrhage than women with a normal body mass index.The authors conducted a cohort study of women who underwent delivery hospitalization in California between 2008 and 2012. Using multilevel regression, the authors examined the relationships between body mass index with hemorrhage (primary outcome), atonic hemorrhage, and severe hemorrhage (secondary outcomes). Stratified analyses were performed according to delivery mode.The absolute event rate for hemorrhage was 60,604/2,176,673 (2.8%). In this cohort, 4% of women were underweight, 49.1% of women were normal body mass index, 25.9% of women were overweight, and 12.7%, 5.2%, and 3.1% of women were in obesity class I, II, and III, respectively. Compared to normal body mass index women, the odds of hemorrhage and atonic hemorrhage were modestly increased for overweight women (hemorrhage: adjusted odds ratio [aOR], 1.06; 99% CI, 1.04 to 1.08; atonic hemorrhage: aOR, 1.07; 99% CI, 1.05 to 1.09) and obesity class I (hemorrhage: aOR, 1.08; 99% CI, 1.05 to 1.11; atonic hemorrhage; aOR, 1.11; 99% CI, 1.08 to 1.15). After vaginal delivery, overweight and obese women had up to 19% increased odds of hemorrhage or atonic hemorrhage; whereas, after cesarean delivery, women in any obesity class had up to 14% decreased odds of severe hemorrhage.The authors' findings suggest that, at most, maternal obesity has a modest effect on hemorrhage risk. The direction of the association between hemorrhage and body mass index may differ by delivery mode.

    View details for PubMedID 29346134

  • Medical Device Design Education: Identifying Problems Through Observation and Hands-On Training. Design and technology education : an international journal Sherman, J., Lee, H. C., Weiss, M. E., Kristensen-Cabrera, A. 2018; 23 (2): 154?74


    Experiential learning, which may include hands-on learning paired with observation and reflection, has been applied in several industries; however, the impact of experiential learning in design education is not well known. We investigated how the type of simulation-based learning could affect the acquisition of knowledge and the ability to synthesize that understanding into insights for medical design innovation. One workshop included observational learning and the other experiential learning with hands-on training. Each course included 14-16 multidisciplinary undergraduate and graduate students. During both workshops, we measured student comprehension of two procedures- infant resuscitation and management of maternal hemorrhage. We focused on the first two phases of design thinking: "Understanding" and "Defining the Problems". Although the course focused on "medical device design", we encouraged students to look beyond the tool to imagine how their design change could impact the entire system. We did not find a significant difference between the scores given to students in the two courses by industry experts. Although the quality of the ideas and execution were similar between both workshops, the instructors noticed that the integration of hands-on training into the second workshop created a higher level of excitement in the class. The methodology and the approach adopted may be relevant to many design problems. In order to better understand the impact of observational learning versus hands-on training, both workshops could be expanded into full quarter classes that allow students to expand their design thinking skills to prototype and test their ideas in the real world.

    View details for PubMedID 31551661

  • Anticipation and preparation for every delivery room resuscitation. Seminars in fetal & neonatal medicine Sawyer, T. n., Lee, H. C., Aziz, K. n. 2018; 23 (5): 312?20


    A majority of babies initiate spontaneous respirations shortly after birth. Up to 10%, however, require resuscitative measures to make the transition from fetus to newborn. Ideally, the need for resuscitation at birth would be predicted before delivery, and a skilled neonatal resuscitation team would be available and ready. This is not always possible. Therefore, neonatal resuscitation teams must be prepared to provide lifesaving resuscitation at every delivery. In this report, we examine risk factors for resuscitation at birth, discuss the importance of communication between obstetric and newborn teams, review key questions to ask before delivery, and investigate antenatal counseling methods. We also investigate ways to prepare for newborn deliveries, including personnel and equipment preparation, and pre-delivery team briefing. Finally, we explore ways in which neonatal resuscitation teams can improve their preparedness through the use of simulation and post-resuscitation debriefing. This report will help neonatal resuscitation teams to anticipate and prepare for every delivery room resuscitation.

    View details for PubMedID 30369405

  • Analyzing the heterogeneity of labor and delivery units: A quantitative analysis of space and design. PloS one Austin, N., Kristensen-Cabrera, A., Sherman, J., Schwandt, D., McDonald, A., Hedli, L., Sie, L., Lipman, S., Daniels, K., Halamek, L. P., Lee, H. C. 2018; 13 (12): e0209339


    This study assessed labor and delivery (L&D) unit space and design, and also considered correlations between physical space measurements and clinical outcomes. Design and human factors research has increased standardization in high-hazard industries, but is not fully utilized in medicine. Emergency department and intensive care unit space has been studied, but optimal L&D unit design is undefined. In this prospective, observational study, a multidisciplinary team assessed physical characteristics of ten L&D units. Design measurements were analyzed with California Maternal Quality Care Collaborative (CMQCC) data from 34,161 deliveries at these hospitals. The hospitals ranged in delivery volumes (<1000->5000 annual deliveries) and cesarean section rates (19.6%-39.7%). Within and among units there was significant heterogeneity in labor room (LR) and operating room (OR) size, count, and number of configurations. There was significant homogeneity of room equipment. Delivery volumes correlated with unit size, room counts, and cesarean delivery rates. Relative risk of cesarean section was modestly increased when certain variables were above average (delivery volume, unit size, LR count, OR count, OR configuration count, LR to OR distance, unit utilization) or below average (LR size, OR size, LR configuration count). Existing variation suggests a gold standard design has yet to be adopted for L&D. A design-centered approach identified opportunities for standardization: 1) L&D unit size and 2) room counts based on current or projected delivery volume, and 3) LR and OR size and equipment. When combined with further human factors research, these guidelines could help design the L&D unit of the future.

    View details for PubMedID 30586446

  • Population-based trends and underlying risk factors for infant respiratory syncytial virus and bronchiolitis hospitalizations. PloS one Bennett, M. V., McLaurin, K. n., Ambrose, C. n., Lee, H. C. 2018; 13 (10): e0205399


    Respiratory syncytial virus (RSV) is a common pathogen during infancy, with the potential to cause serious disease and mortality in high-risk groups. The objective of this study was to characterize trends of RSV and bronchiolitis hospitalizations in the first year in a population-based cohort and assess differences in trends according to risk status.Using an observational retrospective cohort design, we examined a California population-based dataset of vital statistics linked to hospital discharge data for up to 1 year after birth from 1997-2011. Infants were categorized by medical condition and then by gestational age. Medical conditions of interest included chronic lung disease, certain congenital heart diseases, or others known to affect risk for developing severe bronchiolitis. The primary outcome was hospitalization due to RSV; secondary outcome was hospitalization for unspecified bronchiolitis (UB) not coded as RSV. Annual person-year rates were calculated for infants <12 months of age during January to December of each year.Of 7,298,401 infants born during the study period, 121,230 (1.7%) had a medical condition associated with risk; these infants experienced 6853 RSV and 6568 UB hospitalizations in the first year. In infants without medical conditions, 96,694 RSV and 69,886 UB hospitalizations occurred. All-cause infant hospitalizations declined over time from 12.2 to 9.3 per 100 person-years. RSV hospitalization rates for infants with medical conditions decreased from 7.6 to 3.4 per 100 person-years, with the largest relative decline in infants with chronic lung disease (12.0 to 5.0 per 100 person-years). For infants without medical conditions, RSV hospitalizations declined from 1.4 to 0.8 per 100 person-years, with greater decreases among preterm infants with earlier gestational age. UB hospitalization rates remained relatively stable across the study years, from 6.2 to 5.4 and 1.0 to 0.8 per 100 person-years for infants with and without medical conditions.Various interventions may have contributed to observed decreases in RSV hospitalizations from 1998-2011, which were greater in high-risk populations recommended for RSV immunoprophylaxis and not observed with UB. Further efforts to promote evidence-based practice and optimal targeting of appropriate interventions will ensure continued improvement in care for vulnerable infants.

    View details for DOI 10.1371/journal.pone.0205399

    View details for PubMedID 30379957

  • A prospective clinical study of Primo-Lacto: A closed system for colostrum collection. PloS one Kristensen-Cabrera, A. I., Sherman, J. P., Lee, H. C. 2018; 13 (11): e0206854


    Colostrum is the first nutritional liquid that comes out of the breast during lactation. Colostrum collection can be challenging due to the small volume produced, and because breast pumps are not designed for colostrum collection. Besides pumping colostrum, the generally accepted practice is to use any available container to hand-express colostrum. Transfer between containers may lead to contamination, higher chance of infection and loss of colostrum. Our aim was to understand if a dedicated colostrum collection system (Primo-Lacto, Maternal Life, LLC, Palo Alto, CA) is more effective than standard hospital practice.Mothers who delivered preterm infants < 34 weeks gestation and mothers with non-latching infants were approached within 24 hours of delivery. Surveys were distributed to participating patients (n = 67), and nurses or lactation consultants (n = 89). Mothers compared ease of use, their confidence level and satisfaction with the amount collected during standard practice vs. the colostrum collection system. Nurses or lactation consultants compared ease of use, differences in colostrum loss and time invested collecting. Quantitative data were analyzed using the Wilcoxon signed rank test and qualitative data were analyzed with grounded theory methods.For mothers, ease of use and confidence were significantly better when they used the colostrum collection system than when they used the standard collection procedure, and this difference was true for both hand and pump expression (p<0.01). Nurses and lactation consultants perceived that ease of use was better, and percent of colostrum lost was significantly less with the colostrum collection system for both hand and pump expression. The collection times were not significantly different between the colostrum collection system and standard practice.The colostrum collection system is a tool to help facilitate successful colostrum collection and improve the experience both for clinicians and patients.

    View details for PubMedID 30418987

  • Optimal maternal and neonatal outcomes and associated hospital characteristics. Birth (Berkeley, Calif.) Campbell, K. H., Illuzzi, J. L., Lee, H. C., Lin, H. n., Lipkind, H. S., Lundsberg, L. S., Pettker, C. M., Xu, X. n. 2018


    This study aims to examine hospital variation in both maternal and neonatal morbidities and identify institutional characteristics associated with hospital performance in a combined measure of maternal and neonatal outcomes.Using the California Linked Birth File containing data from birth certificate and hospital discharge records, we identified 1 322 713 term births delivered at 248 hospitals during 2010-2012. For each hospital, a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities were calculated after adjusting for patient clinical risk factors. Hospitals were ranked based on combined information on their maternal and newborn morbidity rates.Risk-standardized severe maternal and severe newborn morbidity rates varied substantially across hospitals (10th to 90th percentile range = 67.5-148.2 and 141.8-508.0 per 10 000 term births, respectively), although there was no significant association between the two (P = 0.15). Government hospitals (non-Federal) were more likely than other hospitals to be in worse rank quartiles (P value for trend = 0.004), whereas larger volume was associated with better rank among hospitals in the first three quartiles (P = 0.004). The most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery for mothers, and severe infection, respiratory complication, and shock/resuscitation for neonates.Hospitals with low maternal morbidity rates may not have low neonatal morbidity rates and vice versa, highlighting the importance of assessing joint maternal-newborn outcomes in order to fully characterize a hospital's obstetrical performance. Hospitals with smaller volume and government ownership tend to have less desirable outcomes and warrant additional attention in future quality improvement efforts.

    View details for PubMedID 30251270

  • Neonatal Jaundice Rudolph's Pediatrics Pammi, M., Lee, H. C., Suresh, G. K. edited by Kline, M. W., Blaney, S. M., Giardino, A. P., Orange, J. S., Penny, D. J., Schutze, G. E., Shekerdemian, L. S. McGraw-Hill Education / Medical. 2018; 23rd ed.: 261?264
  • Incidence Trends and Risk Factor Variation in Severe Intraventricular Hemorrhage across a Population Based Cohort. The Journal of pediatrics Handley, S. C., Passarella, M. n., Lee, H. C., Lorch, S. A. 2018


    To quantify the current burden of severe intraventricular hemorrhage (IVH), describe time trends in severe IVH, identify IVH-associated risk factors, and determine the contribution of mediating factors.The retrospective cohort included infants 220/7-316/7 weeks of gestation without severe congenital anomalies, born at hospitals in the California Perinatal Quality Care Collaborative between 2005 and 2015. The primary study outcome was severe (grade III or IV) IVH.Of 44 028 infants, 3371 (7.7%) had severe IVH. The incidence of severe IVH decreased significantly across California from 9.7% in 2005 to 5.9% in 2015. After stratification by gestational age, antenatal steroid exposure was the only factor associated with a decreased odds of severe IVH for all gestational age subgroups. Other factors, including delivery room intubation, were associated with an increased odds of severe IVH, though significance varied by gestational age. Factors analyzed in the mediation analysis accounted for 45.6% (95% CI 38.7%-71.8%) of the reduction in severe IVH, with increased antenatal steroid administration and decreased delivery room intubation mediating a significant proportion of this decrease, 19.4% (95% CI 13.9%-27.5%) and 27.3% (95% CI 20.3%-39.2%), respectively. The unaccounted proportion varied by gestational age.The incidence of severe IVH decreased across California, associated with changes in antenatal steroid exposure and delivery room intubation. Maternal, patient, and delivery room factors accounted for less than one-half of the decrease in severe IVH. Study of other factors, specifically neonatal intensive care unit and hospital-level factors, may provide new insights into policies to reduce severe IVH.

    View details for PubMedID 29754865

  • A Qualitative Analysis of Challenges and Successes in Retinopathy of Prematurity Screening. AJP reports Bain, L. C., Kristensen-Cabrera, A. I., Lee, H. C. 2018; 8 (2): e128?e133


    Objective ?The objective of this study is to identify characteristics of neonatal intensive care unit (NICU) practice that influence successful retinopathy of prematurity (ROP) screening. Study Design ?In this qualitative study, top, improved, and bottom performing NICUs in the California Perinatal Quality Care Collaborative were identified based on ROP screening rates and invited to participate. NICU personnel were interviewed using a semistructured questionnaire. Using thematic analysis, key factors that influence ROP screening were identified. Results ?Themes found in top performing hospitals include a commitment to quality improvement, a committed ophthalmologist, and a system of double checks. Improved NICUs had a common theme of utilizing telemedicine for exams and identification of eligible neonates on admission. The bottom performing hospital struggled with education and identification of eligible neonates and a lack of a dedicated ophthalmologist. Conclusion ?Structure, culture, education, and commitment all contribute to the success of ROP screening in the NICU.

    View details for PubMedID 29896443

    View details for PubMedCentralID PMC5995725

  • Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay. Pediatrics Lee, H. C., Bennett, M. V., Crockett, M. n., Crowe, R. n., Gwiazdowski, S. G., Keller, H. n., Kurtin, P. n., Kuzniewicz, M. n., Mazzeo, A. M., Schulman, J. n., Nisbet, C. C., Sharek, P. J. 2018


    There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS.Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and <32 weeks' gestational age by 3 days. A secondary outcome was "early discharge," the proportion of infants discharged from the hospital before 36 + 5 weeks' PMA. The balancing measure of readmissions within 72 hours was tracked for the collaborative group.From 2013 to 2015, 8917 infants were cared for in 20 collaborative NICUs, 19 individual project NICUs, and 71 nonparticipants. In the collaborative group, the PMA at discharge decreased from 37.8 to 37.5 weeks (P = .02), and early discharge increased from 31.6% to 41.9% (P = .006). The individual project group had no significant change. Nonparticipants had a decrease in PMA from 37.5 to 37.3 weeks (P = .01) but no significant change in early discharge (39.8% to 43.6%; P = .24). There was no significant change in readmissions over time in the collaborative group.A structured collaborative project that was focused on optimizing LOS led to a 3-day decrease in LOS and was more effective than individualized quality improvement efforts.

    View details for PubMedID 29899043

  • Programmatic and Administrative Barriers to High-Risk Infant Follow-Up Care. American journal of perinatology Tang, B. G., Lee, H. C., Gray, E. E., Gould, J. B., Hintz, S. R. 2018; 35 (10): 940?45


    ?This article characterizes programmatic features of a population-based network of high-risk infant follow-up programs and identifies potential challenges associated with attendance from the providers' perspective.?A web-based survey of high-risk infant follow-up program directors, coordinators, and providers of a statewide high-risk infant follow-up system. Frequencies and percentages were used to describe the survey responses.?Of the 68 high-risk infant follow-up programs in California, 56 (82%) responded to the survey. The first visit no-show rate between 10 and 30% was estimated by 44% of programs with higher no-show rates for subsequent visits. Common strategies to remind families of appointments were phone calls and mailings. Most programs (54%) did not have a strategy to help families who lived distant to the high-risk infant follow-up clinic.?High-risk infant follow-up programs may lack resources and effective strategies to enhance follow-up, particularly for those living at a distance.

    View details for PubMedID 29439282

  • Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives. Clinics in perinatology Pai, V. V., Lee, H. C., Profit, J. n. 2018; 45 (2): 165?80


    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

  • Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis. The Journal of pediatrics Nakayuenyongsuk, W. n., Christofferson, M. n., Stevenson, D. K., Sylvester, K. n., Lee, H. C., Park, K. T. 2018


    To establish baseline trends in fecal calprotectin, a protein excreted into the stool when there is neutrophilic inflammation in the bowel, in infants at risk for necrotizing enterocolitis (NEC).We performed a prospective observational cohort study in infants with a birth weight of <1500 g without existing bowel disease at a level IV neonatal intensive care unit from October 2015 to September 2016. Stools were collected once daily for 30 days or until 32 weeks postmenstrual age and processed using the Fecal Calprotectin High Range Quantitative Quantum Blue assay.In 64 preterm infants, during the first week after birth, 62% of infants had an initial stool sample with high baseline calprotectin levels (?200?µg/g). In assessment of maternal and neonatal risk factors, maternal etiology for preterm birth (ie, eclamplsia or preeclampsia) was the only significant factor associated with high baseline calprotectin level. Two patients in the cohort developed NEC. Calprotectin levels for the entire cohort fluctuated during the observed period but generally increased in the third and fourth weeks after birth.At-risk infants had highly variable fecal calprotectin levels, with maternal causes for preterm birth associated with higher baseline levels. More longitudinal data in infants with NEC are necessary to determine whether acute rises in fecal calprotectin levels prior to clinical diagnosis can be confirmed as a diagnostic or prognostic biomarker.

    View details for PubMedID 29519542

  • Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN Lyndon, A. n., Malana, J. n., Hedli, L. C., Sherman, J. n., Lee, H. C. 2018


    To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth.Qualitative description using thematic analysis of interview data.Seventeen women ages 29 to 47 years.Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care.Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during risk moments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety.Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.

    View details for DOI 10.1016/j.jogn.2018.02.008

    View details for PubMedID 29551397

  • Health care and societal costs of bronchopulmonary dysplasia NeoReviews Lapcharoensap, W., Lee, H. C., Nyberg, A., Dukhovny, D. 2018; 19 (4): e211-23

    View details for DOI 10.1542/neo.19-4-e211

  • Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California. Obstetrics and gynecology Lundsberg, L. S., Lee, H. C., Dueñas, G. V., Gregory, K. D., Grossetta Nardini, H. K., Pettker, C. M., Illuzzi, J. L., Xu, X. n. 2018; 131 (2): 214?23


    To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P?.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

    View details for PubMedID 29324608

  • Network analysis: a novel method for mapping neonatal acute transport patterns in California. Journal of perinatology Kunz, S. N., Zupancic, J. A., Rigdon, J., Phibbs, C. S., Lee, H. C., Gould, J. B., Leskovec, J., Profit, J. 2017; 37 (6): 702-708


    The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression.Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001).Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.Journal of Perinatology advance online publication, 23 March 2017; doi:10.1038/jp.2017.20.

    View details for DOI 10.1038/jp.2017.20

    View details for PubMedID 28333155

  • Maternal prepregnancy body mass index and risk of bronchopulmonary dysplasia. Pediatric research Carmichael, S. L., Kan, P., Gould, J. B., Stevenson, D. K., Shaw, G. M., Lee, H. C. 2017


    BackgroundWe examined the relationship between women's prepregnancy BMI and development of bronchopulmonary dysplasia (BPD) in their preterm offspring, hypothesizing that obesity-associated inflammation may increase risk.MethodsWe studied infants born in California between 2007 and 2011, using linked data from California Perinatal Quality Care Collaborative neonatal intensive care units, hospital discharge, and vital statistics. We included infants with birthweight <1,500?g or gestational age at birth of 22-29 weeks. BPD was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age.ResultsAmong 12,621 infants, 4,078 (32%) had BPD. After adjustment for maternal race/ethnicity, age, education, payer source, and infant sex, BMI status underweight I (BMI <16.9, odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3-2.1) and obesity III (BMI ?40.0, OR 1.3, 95% CI 1.0-1.6) were associated with an increased risk of BPD. When considering maternal BMI as a continuous variable, a nonlinear association with BPD was observed for male infants and infants delivered at 25-29 weeks of gestational age, but not for other subgroups.ConclusionBoth high and low maternal BMI were associated with increased BPD risk. These findings support the notion that BPD is a multi-factorial disease that may sometimes have its origins in utero and be influenced by maternal inflammation.Pediatric Research advance online publication, 31 May 2017; doi:10.1038/pr.2017.90.

    View details for DOI 10.1038/pr.2017.90

    View details for PubMedID 28399116

  • Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017


    Background and Objective?Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods?Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results?Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p?=?0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion?Improving teamwork may be an important element in infection control efforts.

    View details for DOI 10.1055/s-0037-1601563

    View details for PubMedID 28395366

  • Variation in quality report viewing by providers and correlation with NICU quality metrics. Journal of perinatology Wahid, N., Bennett, M. V., Gould, J. B., Profit, J., Danielsen, B., Lee, H. C. 2017


    To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality.Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts.The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time.Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.44.

    View details for DOI 10.1038/jp.2017.44

    View details for PubMedID 28383536

  • Trends in Patent Ductus Arteriosus Diagnosis and Management for Very Low Birth Weight Infants PEDIATRICS Ngo, S., Profit, J., Gould, J. B., Lee, H. C. 2017; 139 (4)


    To examine yearly trends of patent ductus arteriosus (PDA) diagnosis and treatment in very low birth weight infants.In this retrospective cohort study of very low birth weight infants (<1500 g) between 2008 and 2014 across 134 California hospitals, we evaluated PDA diagnosis and treatment by year of birth. Infants were either inborn or transferred in within 2 days after delivery and had no congenital abnormalities. Intervention levels for treatment administered to achieve ductal closure were categorized as none, pharmacologic (indomethacin or ibuprofen), both pharmacologic intervention and surgical ligation, or ligation only. Multivariable logistic regression was used to assess risk factors for PDA diagnosis and treatment.PDA was diagnosed in 42.8% (12?002/28?025) of infants, with a decrease in incidence from 49.2% of 4205 infants born in 2008 to 38.5% of 4001 infants born in 2014. Pharmacologic and/or surgical treatment was given to 30.5% of patients. Between 2008 and 2014, the annual rate of infants who received pharmacologic intervention (30.5% vs 15.7%) or both pharmacologic intervention and surgical ligation (6.9% vs 2.9%) decreased whereas infants who were not treated (60.5% vs 78.3%) or received primary ligation (2.2% vs 3.0%) increased.There is an increasing trend toward not treating patients diagnosed with PDA compared with more intensive treatments: pharmacologic intervention or both pharmacologic intervention and surgical ligation. Possible directions for future study include the impact of these trends on hospital-based and long-term outcomes.

    View details for DOI 10.1542/peds.2016-2390

    View details for Web of Science ID 000398602400016

    View details for PubMedID 28562302

  • Thematic analysis of barriers and facilitators to implementation of neonatal resuscitation guideline changes JOURNAL OF PERINATOLOGY Lee, H. C., Arora, V., Brown, T., Lyndon, A. 2017; 37 (3): 249-253


    To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project.Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general.Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation.Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.Journal of Perinatology advance online publication, 1 December 2016; doi:10.1038/jp.2016.217.

    View details for DOI 10.1038/jp.2016.217

    View details for Web of Science ID 000395358000007

    View details for PubMedID 27906192

  • Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320


    To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500?g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

    View details for DOI 10.1038/jp.2016.211

    View details for PubMedID 27853320

  • Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263


    Objective?The objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. Design?This is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). Results?Of 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p?

    View details for DOI 10.1055/s-0036-1586505

    View details for PubMedID 27487231

  • Utility of third trimester sonographic measurements for predicting SGA in cases of fetal gastroschisis. Journal of perinatology Blumenfeld, Y. J., Do, S., Girsen, A. I., DAVIS, A. S., Hintz, S. R., Desai, A. K., Mansour, T., Merritt, T. A., Oshiro, B. T., El-Sayed, Y. Y., Shamshirsaz, A. A., Lee, H. C. 2017


    To assess the accuracy of different sonographic estimated fetal weight (EFW) cutoffs, and combinations of EFW and biometric measurements for predicting small for gestational age (SGA) in fetal gastroschisis.Gastroschisis cases from two centers were included. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for different EFW cutoffs, as well as EFW and biometric measurement combinations.Seventy gastroschisis cases were analyzed. An EFW<10% had 94% sensitivity, 43% specificity, 33% PPV and 96% NPV for SGA at delivery. Using an EFW cutoff of <5% improved the specificity to 63% and PPV to 41%, but decreased the sensitivity to 88%. Combining an abdominal circumference (AC) or femur length (FL) z-score less than -2 with the total EFW improved the specificity and PPV but decreased the sensitivity.A combination of a small AC or FL along with EFW increases the specificity and PPV, but decreases the sensitivity of predicting SGA.Journal of Perinatology advance online publication, 26 January 2017; doi:10.1038/jp.2016.275.

    View details for DOI 10.1038/jp.2016.275

    View details for PubMedID 28125100

  • Opportunities to Foster Efficient Communication in Labor and Delivery Using Simulation. AJP reports Daniels, K., Hamilton, C., Crowe, S., Lipman, S. S., Halamek, L. P., Lee, H. C. 2017; 7 (1): e44-e48


    Introduction?Communication errors are an important contributing factor in adverse outcomes in labor and delivery (L&D) units. The objective of this study was to identify common lapses in verbal communication using simulated obstetrical scenarios and propose alternative formats for communication. Methods?Health care professionals in L&D participated in three simulated clinical scenarios. Scenarios were recorded and reviewed to identify questions repeated within and across scenarios. Questions that were repeated more than once due to ineffective communication were identified. The frequency with which the questions were asked across simulations was identified. Results?Questions were commonly repeated both within and across 27 simulated scenarios. The median number of questions asked was 27 per simulated scenario. Commonly repeated questions focused on three general topics: (1) historical data/information (i.e., estimated gestational age), (2) maternal clinical status (i.e., estimated blood loss), and (3) personnel (i.e., "Has anesthesiologist been called?"). Conclusion?Inefficient verbal communication exists in the process of transferring information during obstetric emergencies. These findings can inform improved training and development of information displays to improve teamwork and communication. A visual display that can report static historical information and specific dynamic clinical data may facilitate optimal human performance.

    View details for DOI 10.1055/s-0037-1599123

    View details for PubMedID 28255522

  • The Relationship of Nosocomial Infection Reduction to Changes in Neonatal Intensive Care Unit Rates of Bronchopulmonary Dysplasia JOURNAL OF PEDIATRICS Lapcharoensap, W., Kan, P., Powers, R. J., Shaw, G. M., Stevenson, D. K., Gould, J. B., Wirtschafter, D. D., Lee, H. C. 2017; 180: 105-?


    To examine whether recent reductions in rates of nosocomial infection have contributed to changes in rates of bronchopulmonary dysplasia (BPD) in a population-based cohort.This was a retrospective, population-based cohort study that used the California Perinatal Quality Care Collaborative database from 2006 to 2013. Eligible infants included those less than 30 weeks' gestational age and less than 1500 g who survived to 3 days of life. Primary variables of interest were rates of nosocomial infections and BPD. Adjusted rates of nosocomial infections and BPD from a baseline period (2006-2010) were compared with a later period (2011-2013). The correlation of changes in rates across periods for both variables was assessed by hospital of care.A total of 22 967 infants from 129 hospitals were included in the study. From the first to second time period, the incidence of nosocomial infections declined from 24.7% to 15% and BPD declined from 35% to 30%. Adjusted hospital rates of BPD and nosocomial infections were correlated positively with a calculated 8% reduction of BPD rates attributable to reductions in nosocomial infections.Successful interventions to reduce rates of nosocomial infections may have a positive impact on other comorbidities such as BPD. The prevention of nosocomial infections should be viewed as a significant component in avoiding long-term neonatal morbidities.

    View details for DOI 10.1016/j.jpeds.2016.09.030

    View details for Web of Science ID 000390028100022

  • Hospital variation in cost of childbirth and contributing factors: a cross-sectional study. BJOG : an international journal of obstetrics and gynaecology Xu, X. n., Lee, H. C., Lin, H. n., Lundsberg, L. S., Pettker, C. M., Lipkind, H. S., Illuzzi, J. L. 2017


    To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation.Cross-sectional analysis of linked birth certificate and hospital discharge data.Two hundred and twenty hospitals in California delivering ? 100 births per year.A total of 405 908 nulliparous term singleton vertex births during 2010-2012.Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models.Cost of childbirth hospitalisation.Median risk-standardised cost of childbirth was $7149 among the hospitals (10th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities.Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care.Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.

    View details for PubMedID 29090498

  • Practices surrounding pulmonary hypertension and bronchopulmonary dysplasia amongst neonatologists caring for premature infants. Journal of perinatology : official journal of the California Perinatal Association Altit, G. n., Lee, H. C., Hintz, S. n., Tacy, T. A., Feinstein, J. A., Bhombal, S. n. 2017


    Pulmonary hypertension (PH) is associated with bronchopulmonary dysplasia (BPD). Screening strategies, a thorough investigation of co-morbidities, and multidisciplinary involvement prior to anti-PH medications have been advocated by recent guidelines. We sought to evaluate current practices of neonatologists caring for premature infants with PH.Electronic survey of American Academy of Pediatrics neonatology members.Among 306 neonatologist respondents, 38% had an institutional screening protocol for patients with BPD; 83% screened at 36 weeks for premature neonates on oxygen/mechanical ventilation. In those practicing more than 5 years, 54% noted increasing numbers of premature infants diagnosed with PH. Evaluation for PH in BPD patients included evaluations for micro-aspiration (41%), airways anomalies (29%), and catheterization (10%). Some degree of acquired pulmonary vein stenosis was encountered in 47%. A majority (90%) utilized anti-PH medications during the neonatal hospitalization.Screening for PH in BPD, and subsequent evaluation and management is highly variable.

    View details for PubMedID 29234146

  • Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics Profit, J. n., Gould, J. B., Bennett, M. n., Goldstein, B. A., Draper, D. n., Phibbs, C. S., Lee, H. C. 2017


    Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.Prospective observational analysis of 18?616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

    View details for PubMedID 28847984

  • Short-term costs of preeclampsia to the United States health care system. American journal of obstetrics and gynecology Stevens, W. n., Shih, T. n., Incerti, D. n., Ton, T. G., Lee, H. C., Peneva, D. n., Macones, G. A., Sibai, B. M., Jena, A. B. 2017


    Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States.This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in 2012.We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set.Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age.In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

    View details for PubMedID 28708975

  • Tackling Quality Improvement in the Delivery Room. Clinics in perinatology Lapcharoensap, W. n., Lee, H. C. 2017; 44 (3): 663?81


    Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.

    View details for PubMedID 28802345

  • Alistair G.S. Philip, MD: Mentor, Teacher, Colleague, Friend NeoReviews Stevenson, D. K., Hay, W. W., Lee, H. C., Wong, R. J. 2017; 18 (12)

    View details for DOI 10.1542/neo.18-12-e688

  • The Effect of Level of Care on Gastroschisis Outcomes. The Journal of pediatrics Apfeld, J. C., Kastenberg, Z. J., Sylvester, K. G., Lee, H. C. 2017; 190: 79?84.e1


    To examine the relationship between level of care in neonatal intensive care units (NICUs) and outcomes for newborns with gastroschisis.A retrospective cohort study was conducted at 130 California Perinatal Quality Care Collaborative NICUs from 2008 to 2014. All gastroschisis births were examined according to American Academy of Pediatrics NICU level of care at the birth hospital. Multivariate analyses examined odds of mortality, duration of mechanical ventilation, and duration of stay.For 1588 newborns with gastroschisis, the adjusted odds of death were higher for those born into a center with a level IIA/B NICU (OR, 6.66; P?=?.004), a level IIIA NICU (OR, 5.95; P?=?.008), or a level IIIB NICU (OR, 5.85; P?=?.002), when compared with level IIIC centers. The odds of having more days on ventilation were significantly higher for births at IIA/B and IIIB centers (OR, 2.05 [P?

    View details for PubMedID 29144275

  • Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity. JAMA pediatrics Schulman, J. n., Braun, D. n., Lee, H. C., Profit, J. n., Duenas, G. n., Bennett, M. V., Dimand, R. J., Jocson, M. n., Gould, J. B. 2017


    Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission.To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care.Cross-sectional study of 35?921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity.Live birth at GA of 34 weeks or more.Inborn NICU admission rate.Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ??=?-0.3034, P?

    View details for PubMedID 29181499

  • Opportunities for maternal transport for delivery of very low birth weight infants JOURNAL OF PERINATOLOGY Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2017; 37 (1): 32-35


    To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500?g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1?508?143 births, 13?919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24?h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

    View details for DOI 10.1038/jp.2016.174

    View details for Web of Science ID 000391517000007

  • Variation in Hospital Intrapartum Practices and Association With Cesarean Rate JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Lundsberg, L. S., Illuzzi, J. L., Gariepy, A. M., Sheth, S. S., Pettker, C. M., Lee, H. C., Lipkind, H. S., Xu, X. 2017; 46 (1): 5-17


    To examine hospital variation in intrapartum care and its relationship with cesarean rates.Cross-sectional survey.Connecticut and Massachusetts hospitals providing obstetric services.Nurse managers or other clinical staff knowledgeable about intrapartum care.We assessed labor and birth unit capacity and staffing, fetal monitoring, labor management, intrapartum interventions, newborn care, quality assurance, and performance review practices. Association of hospital characteristics and intrapartum practices with cesarean rate was evaluated using Wilcoxon exact rank sum test and Kendall's tau-b correlation coefficient.Among 60 eligible hospitals, respondents from 39 hospitals (65%) completed the survey. Cesarean rates varied from 21% to 42% (median = 30%). Regular review of cesarean rates and indications (85%), regular provision of feedback on cesarean rates and indications to physicians (80%), and regular review of vaginal birth after cesarean rates (94%) were commonly performed at responding hospitals. These practices, however, were not associated with hospital cesarean rate. Hospitals that offered cesarean at the request of the woman (p < .01) and had more liberal indications for labor induction (p < .01) and cesarean birth (p < .01) had significantly greater cesarean rates than institutions without these practices. Routinely placing an intravenous line (p < .01) and drawing blood for complete blood count/type and antibody screen (p < .01) in low-risk women were associated with greater cesarean rates; having a certified nurse-midwife in house at all times (p = .01) and permitting women to eat during labor (p = .02) were associated with lower cesarean rates.Intrapartum practices of hospitals varied markedly. These different patterns of care may suggest differing levels of intrapartum intervention.

    View details for DOI 10.1016/j.jogn.2016.07.011

    View details for Web of Science ID 000396438700006

    View details for PubMedID 27886948

  • Effects of delivery room quality improvement on premature infant outcomes. Journal of perinatology Lapcharoensap, W., Bennett, M. V., Powers, R. J., Finer, N. N., Halamek, L. P., Gould, J. B., Sharek, P. J., Lee, H. C. 2016


    Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ?1500?g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.Journal of Perinatology advance online publication, 22 December 2016; doi:10.1038/jp.2016.237.

    View details for DOI 10.1038/jp.2016.237

    View details for PubMedID 28005062

  • Characteristics of neonatal transports in California JOURNAL OF PERINATOLOGY Akula, V. P., Gould, J. B., Kan, P., Bollman, L., Profit, J., Lee, H. C. 2016; 36 (12): 1122-1127


    To describe the current scope of neonatal inter-facility transports.California databases were used to characterize infants transported in the first week after birth from 2009 to 2012.Transport of the 22?550 neonates was classified as emergent 9383 (41.6%), urgent 8844 (39.2%), scheduled 2082 (9.2%) and other 85 (0.4%). In addition, 2152 (9.5%) were initiated for delivery attendance. Most transports originated from hospitals without a neonatal intensive care unit (68%), with the majority transferred to regional centers (66%). Compared with those born and cared for at the birth hospital, the odds of being transported were higher if the patient's mother was Hispanic, <20 years old, or had a previous C-section. An Apgar score <3 at 10 min of age, cardiac compressions in the delivery room, or major birth defect were also risk factors for neonatal transport.As many neonates receive transport within the first week after birth, there may be opportunities for quality improvement activities in this area.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.102.

    View details for DOI 10.1038/jp.2016.102

    View details for Web of Science ID 000389735700019

    View details for PubMedID 27684413

  • Comparing NICU teamwork and safety climate across two commonly used survey instruments BMJ QUALITY & SAFETY Profit, J., Lee, H. C., Sharek, P. J., Kan, P., Nisbet, C. C., Thomas, E. J., Etchegaray, J. M., Sexton, B. 2016; 25 (12): 954-961


    Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

    View details for DOI 10.1136/bmjqs-2014-003924

    View details for PubMedID 26700545

  • Update on simulation for the Neonatal Resuscitation Program. Seminars in perinatology Ades, A., Lee, H. C. 2016


    The goal of the Neonatal Resuscitation Program is to have a trained provider in neonatal resuscitation at every delivery. The Neonatal Resuscitation Program develops its course content on review of the scientific evidence available for the resuscitation of newborns. Just as importantly, the educational structure and delivery of the course are based on evidence and educational theory. Thus, as simulation became a more accepted model in medical education and evidence was developing suggesting benefit of simulation, the Neonatal Resuscitation Program officially added simulation into its courses in 2010. Simulation-based medical education is now an integral part of the Neonatal Resuscitation Program courses both in teaching the psychomotor skills as well as the teamwork skills needed for effective newborn resuscitations. While there is evidence, as in other fields, suggesting that simulation for teaching newborn resuscitation is beneficial whether using high- or low-technology manikins or video-assisted debriefing or not, there are still many unanswered questions as to best practice and patient outcome effects.

    View details for DOI 10.1053/j.semperi.2016.08.005

    View details for PubMedID 27823817

  • The Relationship of Nosocomial Infection Reduction to Changes in Neonatal Intensive Care Unit Rates of Bronchopulmonary Dysplasia. journal of pediatrics Lapcharoensap, W., Kan, P., Powers, R. J., Shaw, G. M., Stevenson, D. K., Gould, J. B., Wirtschafter, D. D., Lee, H. C. 2016


    To examine whether recent reductions in rates of nosocomial infection have contributed to changes in rates of bronchopulmonary dysplasia (BPD) in a population-based cohort.This was a retrospective, population-based cohort study that used the California Perinatal Quality Care Collaborative database from 2006 to 2013. Eligible infants included those less than 30 weeks' gestational age and less than 1500 g who survived to 3 days of life. Primary variables of interest were rates of nosocomial infections and BPD. Adjusted rates of nosocomial infections and BPD from a baseline period (2006-2010) were compared with a later period (2011-2013). The correlation of changes in rates across periods for both variables was assessed by hospital of care.A total of 22 967 infants from 129 hospitals were included in the study. From the first to second time period, the incidence of nosocomial infections declined from 24.7% to 15% and BPD declined from 35% to 30%. Adjusted hospital rates of BPD and nosocomial infections were correlated positively with a calculated 8% reduction of BPD rates attributable to reductions in nosocomial infections.Successful interventions to reduce rates of nosocomial infections may have a positive impact on other comorbidities such as BPD. The prevention of nosocomial infections should be viewed as a significant component in avoiding long-term neonatal morbidities.

    View details for DOI 10.1016/j.jpeds.2016.09.030

    View details for PubMedID 27742123

  • Trends in the delivery route of twin pregnancies in the United States, 2006-2013. European journal of obstetrics, gynecology, and reproductive biology Bateni, Z. H., Clark, S. L., Sangi-Haghpeykar, H., Aagaard, K. M., Blumenfeld, Y. J., Ramin, S. M., Lee, H. C., Fox, K. A., Moaddab, A., Shamshirsaz, A. A., Salmanian, B., Hosseinzadeh, P., Racusin, D. A., Erfani, H., Espinoza, J., Dildy, G. A., Belfort, M. A., Shamshirsaz, A. A. 2016; 205: 120-126


    To determine the trends of cesarean delivery rate among twin pregnancies from 2006 to 2013.This is a population-based, cross-sectional analysis of twin live births from United State birth data files of the National Center for Health Statistics for calendar years 2006 through 2013. We stratified the population based on the gestational age groups, maternal race/ethnicity, advanced maternal age (AMA) which was defined by age more than 35 years and within the standard birth weight groups (group 1: birth weight 500-1499g, group 2: birth weight 1500-2499g and group 3: birth weight >2500g). We also analyzed the effect of different risk factors for cesarean delivery in twins.There were 1,079,102 infants born of twin gestations in the U.S. from 2006 to 2013, representing a small but significant increase in the proportion of twin births among all births (3.2% in 2006 versus 3.4% in 2013). The rate of cesarean delivery in twin live births peaked at 75.3% in 2009, and was significantly lower (74.8%) in 2013. The rate of the twin live birth with the breech presentation increased steadily from 26.3% in 2006 to 29.1% in 2013. For the fetus of the twin pregnancy presented as breech, the cesarean delivery rate peaked at 92.2% in 2010, falling slightly but significantly in the ensuing 3 years. The results demonstrated that the decrease in cesarean delivery rate was due to fewer cesareans in non-Hispanic white patients; all other ethnic subgroups showed increasing rates of cesarean delivery throughout the study. Gestational diabetes, gestational hypertension, previous cesarean delivery and breech presentation were all significant risk factors for cesarean delivery during the entire study period. Induction of labor and premature rupture of the membranes were associated with lower rates of cesarean delivery in twins.The recent decrease in the cesarean delivery rate in twin gestation appears to be largely attributable to a decline in cesarean among pregnancies complicated by breech presentation in non-Hispanic white women, and may reflect a health care disparity that deserves further research.

    View details for DOI 10.1016/j.ejogrb.2016.08.031

    View details for PubMedID 27591713

  • Case 1: Constipation, Irritability, and Poor Feeding in 2-month-old Boy. Pediatrics in review Shah, N. A., Lee, H. C. 2016; 37 (9): 391-393

    View details for DOI 10.1542/pir.2014-0114

    View details for PubMedID 27587641

  • Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight. Academic pediatrics Eneriz-Wiemer, M., Saynina, O., Sundaram, V., Lee, H. C., Bhattacharya, J., Sanders, L. M. 2016; 16 (7): 645-652


    Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age ?32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

    View details for DOI 10.1016/j.acap.2016.04.004

    View details for PubMedID 27130810

  • Inhaled nitric oxide use in preterm infants in California neonatal intensive care units. Journal of perinatology Handley, S. C., Steinhorn, R. H., Hopper, A. O., Govindaswami, B., BHATT, D. R., Van Meurs, K. P., Ariagno, R. L., Gould, J. B., Lee, H. C. 2016; 36 (8): 635-639


    To describe inhaled nitric oxide (iNO) exposure in preterm infants and variation in neonatal intensive care unit (NICU) use.This was a retrospective cohort study of infants, 22 to 33+6/7 weeks of gestational age (GA), during 2005 to 2013. Analyses were stratified by GA and included population characteristics, iNO use over time and hospital variation.Of the 65?824 infants, 1718 (2.61%) received iNO. Infants, 22 to 24+6/7 weeks of GA, had the highest incidence of iNO exposure (6.54%). Community NICUs (n=77, median hospital use rate 0.7%) used less iNO than regional NICUs (n=23, median hospital use rate 5.8%). In 22 to 24+6/7 weeks of GA infants, the median rate in regional centers was 10.6% (hospital interquartile range 3.8% to 22.6%).iNO exposure varied with GA and hospital level, with the most use in extremely premature infants and regional centers. Variation reflects a lack of consensus regarding the appropriate use of iNO for preterm infants.Journal of Perinatology advance online publication, 31 March 2016; doi:10.1038/jp.2016.49.

    View details for DOI 10.1038/jp.2016.49

    View details for PubMedID 27031320

  • Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Joint Commission journal on quality and patient safety / Joint Commission Resources Stone, S., Lee, H. C., Sharek, P. J. 2016; 42 (7): 309-315


    The California Perinatal Quality Care Collaborative led the Breastmilk Nutrition Quality Improvement Collaborative from October 2009 to September 2010 to increase the percentage of very low birth weight infants receiving breast milk at discharge in 11 collaborative neonatal ICUs (NICUs). Observed increases in breast milk feeding and decreases in necrotizing enterocolitis persisted for 6 months after the collaborative ended. Eighteen to 24 months after the end of the collaborative, some sites maintained or further increased their gains, while others trended back toward baseline. A study was conducted to assess the qualitative factors that affect sustained improvement following participation.Collaborative leaders at each of the 11 NICUs that participated in the Breastmilk Nutrition Quality Improvement Collaborative were invited to participate in a site-specific one-hour phone interview. Interviews were recorded and transcribed and then analyzed using qualitative research analysis software to identify themes associated with sustained improvement.Eight of 11 invited centers agreed to participate in the interviews. Thematic saturation was achieved by the sixth interview, so further interviews were not pursued. Factors contributing to sustainability included physician involvement within the multidisciplinary teams, continuous education, incorporation of interventions into the daily work flow, and integration of a data-driven feedback system.Early consideration by site leaders of how to integrate best-practice interventions into the daily work flow, and ensuring physician commitment and ongoing education based in continuous data review, should enhance the likelihood of sustaining improvements. To maximize sustained success, future collaborative design should consider proactively identifying and supporting these factors at participating sites.

    View details for PubMedID 27301834

  • Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B., Profit, J. 2016; 33 (8): 751-757


    Objective?Develop length of stay prediction models for neonatal intensive care unit patients. Study Design?We used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. Results?Our sample included 23,551 patients. Median length of stay was 79 days when birth weight was?

    View details for DOI 10.1055/s-0036-1572433

    View details for PubMedID 26890437

  • Impact of antenatal steroids on intraventricular hemorrhage in very-low-birth weight infants JOURNAL OF PERINATOLOGY Wei, J. C., Catalano, R., Profit, J., Gould, J. B., Lee, H. C. 2016; 36 (5): 352-356


    To determine the association between antenatal steroids administration and intraventricular hemorrhage rates.We used cross-sectional data from the California Perinatal Quality Care Collaborative during 2007 to 2013 for infants ?32 weeks gestational age. Using multivariable logistic regression, we evaluated the effect of antenatal steroids on intraventricular hemorrhage, stratified by gestational age.In 25?979 very-low-birth weight infants, antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage (odds ratio=0.68, 95% confidence interval: 0.62, 0.75) and a reduction in incidence of severe intraventricular hemorrhage (odds ratio=0.51, 95% confidence interval: 0.45, 0.58). This association was seen across gestational ages ranging from 22 to 29 weeks.Although current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation, our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age.

    View details for DOI 10.1038/jp.2016.38

    View details for Web of Science ID 000374914900006

    View details for PubMedID 27010109

  • The Association of Level of Care With NICU Quality. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2016; 137 (3): 1-9


    Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21?051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

    View details for DOI 10.1542/peds.2014-4210

    View details for PubMedID 26908663

  • Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates. Pediatrics Kantorowska, A., Wei, J. C., Cohen, R. S., Lawrence, R. A., Gould, J. B., Lee, H. C. 2016; 137 (3): 1-8


    To examine the availability of donor human milk (DHM) in a population-based cohort and assess whether the availability of DHM was associated with rates of breast milk feeding at NICU discharge and rates of necrotizing enterocolitis (NEC).Individual patient clinical data for very low birth weight infants from the California Perinatal Quality Care Collaborative were linked to hospital-level data on DHM availability from the Mothers' Milk Bank of San José for 2007 to 2013. Trends of DHM availability were examined by level of NICU care. Hospitals that transitioned from not having DHM to having DHM availability during the study period were examined to assess changes in rates of breast milk feeding at NICU discharge and NEC.The availability of DHM increased from 27 to 55 hospitals during the study period. The availability increased for all levels of care including regional, community, and intermediate NICUs, with the highest increase occurring in regional NICUs. By 2013, 81.3% of premature infants cared for in regional NICUs had access to DHM. Of the 22 hospitals that had a clear transition to having availability of DHM, there was a 10% increase in breast milk feeding at NICU discharge and a concomitant 2.6% decrease in NEC rates.The availability of DHM has increased over time and has been associated with positive changes including increased breast milk feeding at NICU discharge and decrease in NEC rates.

    View details for DOI 10.1542/peds.2015-3123

    View details for PubMedID 26908696

  • Optimal Criteria Survey for Preresuscitation Delivery Room Checklists. American journal of perinatology Brown, T., Tu, J., Profit, J., Gupta, A., Lee, H. C. 2016; 33 (2): 203-207


    Objective?To investigate the optimal format and content of delivery room reminder tools, such as checklists. Study Design?Voluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. Results?Fifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. Conclusions?Clinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.

    View details for DOI 10.1055/s-0035-1564064

    View details for PubMedID 26368913

  • Temperature Management in the Delivery Room and During Neonatal Resuscitation NeoReviews Lapcharoensap, W., Lee, H. C. 2016; 17 (8)

    View details for DOI 10.1542/neo.17-8-e454

  • International Perspectives: Reducing Birth Asphyxia in China by Implementing the Neonatal Resuscitation Program and Helping Babies Breathe Initiative NeoReviews Xu, T., Niermeyer, S., Lee, H. C., Simon, W. M., Yue, Q., Gong, L., Wang, H. 2016; 17 (8)

    View details for DOI 10.1542/neo.17-8-e425

  • Platelet count and associated morbidities in VLBW infants with pharmacologically treated patent ductus arteriosus JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Murphy, D. P., Lee, H. C., Payton, K. S., Powers, R. J. 2016; 29 (13): 2045-2048


    Characterize the diagnosis of PDA and the distribution of pretreatment platelet count in pharmacologically managed PDA in infants ?1500?g and assess the relationship of platelet count to serious morbidities.This is a retrospective, observational study. In 40 hospitals, data were collected on PDA, including pretreatment platelet count. Distribution of platelet count was examined. The association of platelet count and clinical outcomes of IVH, NEC and PDA closure prior to discharge were examined. Chi-square test was used to compare outcomes by platelet count groups.There were 311 patients treated with medically treated PDA. Pretreatment platelet counts were categorized as 0-119?K, 120-199?K, 200-299?K, >300?K. Incidence and grade of IVH were not significantly different by platelet group. Across all groups: No IVH 62-83%, Grades 1-2 IVH 13-25%, Grades 3-4 IVH 2-13%. NEC occurred in 0-11% of all patients studied. PDA closure rate was 33-45%.PDA closure was not significantly affected by platelet count. Platelet count was not a statistically significant factor for development of IVH and NEC in infants born <1500?g with pharmacologically treated PDA.

    View details for DOI 10.3109/14767058.2015.1076785

    View details for PubMedID 26365622

  • Postnatal growth failure in very low birthweight infants born between 2005 and 2012. Archives of disease in childhood. Fetal and neonatal edition Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2016; 101 (1): 50-55


    Postnatal growth restriction is common in preterm infants and is associated with long-term neurodevelopmental impairment. Recent trends in postnatal growth restriction are unclear.Birth and discharge weights from 25?899 Californian very low birthweight infants (birth weight 500-1500?g, gestational age 22-32?weeks) who were born between 2005 and 2012 were converted to age-specific Z-scores and analysed using multivariable modelling.Birthweight Z-score did not change between 2005 and 2012. However, the adjusted discharge weight Z-score increased significantly by 0.168 Z-scores (0.154, 0.182) over the study period, and the adjusted fall in weight Z-score between birth and discharge decreased significantly between those dates (by 0.016 Z-scores/year). The proportion of infants who were discharged home below the 10th weight-for-age centile or had a fall in weight Z-score between birth and discharge of >1 decreased significantly over time. The comorbidities most associated with poorer postnatal growth were medical or surgical necrotising enterocolitis, isolated gastrointestinal perforation and severe retinopathy of prematurity, which were associated with an adjusted mean reduction in discharge weight Z-score of 0.24, 0.57, 0.46 and 0.32, respectively. Chronic lung disease was not a risk factor after accounting for length of stay.Postnatal, but not prenatal, growth improved among very low birthweight infants between 2005 and 2012. Neonatal morbidities including necrotising enterocolitis, gastrointestinal perforations and severe retinopathy of prematurity have significant negative effects on postnatal growth.

    View details for DOI 10.1136/archdischild-2014-308095

    View details for PubMedID 26201534

  • Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants PEDIATRICS Greenberg, R. G., Cochran, K. M., Smith, P. B., Edson, B. S., Schulman, J., Lee, H. C., Govindaswami, B., Pantoja, A., Hardy, D., Curran, J., Lin, D., Kuo, S., Noguchi, A., Ittmann, P., Duncan, S., Gupta, M., Picarillo, A., Karna, P., Cohen, M., Giuliano, M., Carroll, S., Page, B., Guzman-Cottrill, J., Walker, M. W., Garland, J., Ancona, J. K., Ellsbury, D. L., Laughon, M. M., McCaffrey, M. J. 2015; 136 (6): 1080-1086


    Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI.Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type.Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1.Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

    View details for DOI 10.1542/peds.2015-0573

    View details for PubMedID 26574587

  • Effect of time of birth on maternal morbidity during childbirth hospitalization in California. American journal of obstetrics and gynecology Lyndon, A., Lee, H. C., Gay, C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2015; 213 (5): 705 e1-705 e11


    This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization.Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models.The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjusted odds ratio [AOR], 1101-1500 = 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900 = 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300 = 1.31; 95% CI, 1.21-1.41; 0301-0700 = 1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday = 1.00; 95% CI, 0.98-1.02]; Sunday = 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday = 1.09; 95% CI, 1.00-1.18; Sunday = 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity.Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.

    View details for DOI 10.1016/j.ajog.2015.07.018

    View details for PubMedID 26196454

    View details for PubMedCentralID PMC4631702

  • Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics Perlman, J. M., Wyllie, J., Kattwinkel, J., Wyckoff, M. H., Aziz, K., Guinsburg, R., Kim, H., Liley, H. G., Mildenhall, L., Simon, W. M., Szyld, E., Tamura, M., Velaphi, S. 2015; 136: S120-66

    View details for DOI 10.1542/peds.2015-3373D

    View details for PubMedID 26471381

  • Effects of race/ethnicity and BMI on the association between height and risk for spontaneous preterm birth AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Shachar, B. Z., Mayo, J. A., Lee, H. C., Carmichael, S. L., Stevenson, D. K., Shaw, G. M., Gould, J. B. 2015; 213 (5)

    View details for DOI 10.1016/j.ajog.2015.07.005

    View details for Web of Science ID 000365763400027

    View details for PubMedID 26187451

  • Multimodality Renal Failure in a Patient with OEIS Complex. AJP reports Santoro, J. D., Chao, S., Hsieh, M. H., Lee, H. C. 2015; 5 (2): e161-4


    Omphalocele-exstrophy of the bladder-imperforate anus-spinal defect (OEIS) complex is a rare constellation of clinical abnormalities with wide phenotypic presentation. We describe a case of a preterm neonate with OEIS complex with acute renal failure, and the challenges in diagnosis and management of this patient as renal failure can be a multifactorial process when encountered with this rare complex.

    View details for DOI 10.1055/s-0035-1554799

    View details for PubMedID 26495176

    View details for PubMedCentralID PMC4603852

  • Neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations RESUSCITATION Wyllie, J., Perlman, J. M., Kattwinkel, J., Wyckoff, M. H., Aziz, K., Guinsburg, R., Kim, H., Liley, H. G., Mildenhall, L., Simon, W. M., Szyld, E., Tamura, M., Velaphi, S. 2015; 95: E169-E201
  • Maternal Asthma, Preterm Birth, and Risk of Bronchopulmonary Dysplasia. journal of pediatrics Gage, S., Kan, P., Lee, H. C., Gould, J. B., Stevenson, D. K., Shaw, G. M., O'Brodovich, H. M. 2015; 167 (4): 875-880 e1


    To study the relationship between maternal asthma and the development of bronchopulmonary dysplasia (BPD).Using a large population-based California cohort, we investigated associations between maternal asthma and preterm birth subtype, as well as maternal asthma and BPD. We used data from 2007-2010 maternal delivery discharge records of 2?009?511 pregnancies and International Classification of Diseases, Ninth Revision codes. Preterm birth was defined as <37 weeks gestational age (GA), with subgroups of <28 weeks, 28-32 weeks, and 33-37 weeks GA, as well as preterm subtype, defined as spontaneous, medically indicated, or unknown. Linkage between the 2 California-wide datasets yielded 21?944 singleton preterm infants linked to their mother's records, allowing estimation of the risk of BPD in mothers with asthma and those without asthma.Maternal asthma was associated with increased odds (OR, 1.42; 95% CI, 1.38-1.46) of preterm birth at <37 weeks GA, with the greatest risk for 28-32 GA (aOR, 1.60; 95% CI, 1.47-1.74). Among 21?944 preterm infants, we did not observe an elevated risk for BPD in infants born to mothers with asthma (aOR, 1.03; 95% CI, 0.9-1.2). Stratification by maternal treatment with antenatal steroids revealed increased odds of BPD in infants whose mothers had asthma but did not receive antenatal steroids (aOR, 1.54; 95% CI, 1.15-2.06), but not in infants whose mothers had asthma and were treated with antenatal steroids (aOR, 0.85; 95% CI, 0.67-1.07).Asthma in mothers who did not receive antenatal steroid treatment is associated with an increased risk of BPD in their preterm infants.

    View details for DOI 10.1016/j.jpeds.2015.06.048

    View details for PubMedID 26254835

  • Neonatal Intensive Care Unit Antibiotic Use PEDIATRICS Schulman, J., Dimand, R. J., Lee, H. C., Duenas, G. V., Bennett, M. V., Gould, J. B. 2015; 135 (5): 826-833


    Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay.In a retrospective cohort study of 52?061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

    View details for DOI 10.1542/peds.2014-3409

    View details for PubMedID 25896845

  • Obstetric Ultrasound Quality Improvement Initiative-Utilization of a Quality Assurance Process and Standardized Checklists AMERICAN JOURNAL OF PERINATOLOGY Mrazek-Pugh, B., Blumenfeld, Y. J., Lee, H. C., Chueh, J. 2015; 32 (6): 599-604


    Objective?Our aim was to assess whether mandated completion of an electronic checklist and a quality assurance (QA) process improved obstetric (OB) ultrasound image documentation. Study Design?A checklist of mandated images based on the American Institute of Ultrasound in Medicine guidelines was created. A baseline QA assessment was performed with a lead senior sonographer reviewing eight random OB examinations for each sonographer. An electronic checklist was then instituted for all OB examinations on each ultrasound machine. It was mandated that each anatomical structure be checked off during real-time image acquisition. A repeat QA assessment of each sonographer was then performed quarterly. Results?Baseline assessments were performed between September 2011 and November 2011. Out of the 110 examinations analyzed, only 49% were deemed "complete" with none of the sonographers having a 100% complete examination rate. Following institution of the mandated electronic checklist, a repeat assessment revealed an 81% complete examination rate for the next quarter, and 90% were complete at the end of a year. All sonographers improved their image acquisition regardless of baseline skill level at the initial QA. Conclusion?A QA process and a mandated standardized electronic checklist improved the image documentation.

    View details for DOI 10.1055/s-0035-1545667

    View details for Web of Science ID 000354342400013

    View details for PubMedID 25730132

  • Correlation of continuous glucose monitoring profiles with pregnancy outcomes in nondiabetic women. American journal of perinatology Sung, J. F., Kogut, E. A., Lee, H. C., Mannan, J. L., Navabi, K., Taslimi, M. M., El-Sayed, Y. Y. 2015; 32 (5): 461-468


    Objective?To determine whether hyperglycemic excursions detected by continuous glucose monitoring (CGM) correlate with birth weight percentile and other pregnancy outcomes, and whether CGM correlates better with these outcomes than a single glucose value from a 1-hour glucose challenge test (GCT). Study Design?This was a prospective observational study of 55 pregnant patients without preexisting diabetes, who wore a CGM device for up to 7 days, between 24 and 28 weeks' gestation. The area under the curve (AUC) of hyperglycemic excursions above various thresholds (110, 120, 130, 140, and 180 mg/dL) was calculated. These AUC values, and results from a standard 50-g GCT, were correlated with our primary outcome of birth weight percentile, and secondary outcomes of unplanned operative delivery, pregnancy complications, delivery complications, fetal complications, and neonatal complications. Results?A consistent correlation was seen between all AUC thresholds and birth weight percentile (r?=?0.29, p?

    View details for DOI 10.1055/s-0034-1390344

    View details for PubMedID 25262455

  • Correlation of Continuous Glucose Monitoring Profiles with Pregnancy Outcomes in Nondiabetic Women AMERICAN JOURNAL OF PERINATOLOGY Sung, J. F., Kogut, E. A., Lee, H. C., Mannan, J. L., Navabi, K., Taslimi, M. M., El-Sayed, Y. Y. 2015; 32 (5): 461-467


    Objective?To determine whether hyperglycemic excursions detected by continuous glucose monitoring (CGM) correlate with birth weight percentile and other pregnancy outcomes, and whether CGM correlates better with these outcomes than a single glucose value from a 1-hour glucose challenge test (GCT). Study Design?This was a prospective observational study of 55 pregnant patients without preexisting diabetes, who wore a CGM device for up to 7 days, between 24 and 28 weeks' gestation. The area under the curve (AUC) of hyperglycemic excursions above various thresholds (110, 120, 130, 140, and 180 mg/dL) was calculated. These AUC values, and results from a standard 50-g GCT, were correlated with our primary outcome of birth weight percentile, and secondary outcomes of unplanned operative delivery, pregnancy complications, delivery complications, fetal complications, and neonatal complications. Results?A consistent correlation was seen between all AUC thresholds and birth weight percentile (r?=?0.29, p?

    View details for DOI 10.1055/s-0034-1390344

    View details for Web of Science ID 000352807900006

    View details for PubMedID 25262455

  • Hospital Variation in Medical and Surgical Treatment of Patent Ductus Arteriosus AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Durand, D. J., Danielsen, B., Duenas, G. V., Powers, R. J. 2015; 32 (4): 379-385


    Objective?This study aims to characterize population risks for diagnosis, medical treatment, and surgical ligation of patent ductus arteriosus (PDA) in very low-birth-weight infants. Study Design?Maternal and neonatal data were collected in 40 hospitals in California during 2011 for infants with birth weight???1,500?g without any congenital malformation, with a diagnosis of PDA. Multivariable logistic regression was used to determine independent risks for PDA diagnosis and for surgical ligation. Results?There were 770/1,902 (40.4%) infants diagnosed with PDA. Low birth weight, gestational age, respiratory distress syndrome, and surfactant administration were associated with PDA diagnosis. Ligation occurred in 43% of patients with birth weight???750?g, in 24% of patients weighing between 715 and 1,000?g, and in 12% of patients weighing from 1,001 to 1,500 g. Older gestational age (1?week, odds ratio 0.55, 95% confidence interval 0.48-0.63) and absence of respiratory distress syndrome (odds ratio 0.14, 95% confidence interval 0.03-0.59) were associated with lower ligation risk. The median hospital ligation rate was 14% (interquartile range 0-38%). Conclusion?Most patients with PDA receive treatment for closure. Practice variation may set the stage for further exploration of experimental trials.

    View details for DOI 10.1055/s-0034-1387931

    View details for Web of Science ID 000351664400011

    View details for PubMedID 25241108

  • Magnesium sulfate exposure and neonatal intensive care unit admission at term. Journal of perinatology Girsen, A. I., Greenberg, M. B., El-Sayed, Y. Y., LEE, H., Carvalho, B., Lyell, D. J. 2015; 35 (3): 181-185


    Objective:The aim of this study was to investigate the effect of maternal magnesium sulfate (MgSO4) exposure for eclampsia prophylaxis on neonatal intensive care unit (NICU) admission rates for term newborns.Study Design:A secondary analysis of the Maternal-Fetal Medicine Unit Network Cesarean Registry, including primary and repeat cesarean deliveries, and failed and successful trials of labor after cesarean was conducted. Singleton pregnancies among women with preeclampsia and >37 weeks of gestation were included. Pregnancies with uterine rupture, chorioamnionitis and congenital malformations were excluded. Logistic regression analysis was used to determine associations between MgSO4 exposure and NICU admission. P<0.05 was considered statistically significant.Result:Two thousand one hundred and sixty-six term pregnancies of women with preeclampsia were included, of whom 1747 (81%) received MgSO4 for eclampsia prophylaxis and 419 (19%) did not. NICU admission rates were higher among newborns exposed to MgSO4 vs unexposed (22% vs 12%, P<0.001). After controlling for neonatal birth weight, gestational age and maternal demographic and obstetric factors, NICU admission remained significantly associated with antenatal MgSO4 exposure (adjusted odds ratio 1.9, 95% confidence interval 1.3 to 2.6, P<0.001). Newborns exposed to MgSO4 were more likely to have Apgar scores <7 at 1 and 5?min (15% vs 11% unexposed, P=0.01 and 3% vs 0.7% unexposed, P=0.008). There were no significant differences in NICU length of stay (median 5 (range 2 to 91) vs 6 (3 to 15), P=0.5).Conclusion:Antenatal maternal MgSO4 treatment was associated with increased NICU admission rates among exposed term newborns of mothers with preeclampsia. This study highlights the need for studies of maternal MgSO4 administration protocols that optimize maternal and fetal benefits and minimize risks.Journal of Perinatology advance online publication, 16 October 2014; doi:10.1038/jp.2014.184.

    View details for DOI 10.1038/jp.2014.184

    View details for PubMedID 25321647

  • Impact of a novel decision support tool on adherence to Neonatal Resuscitation Program algorithm RESUSCITATION Fuerch, J. H., Yamada, N. K., Coelho, P. R., Lee, H. C., Halamek, L. P. 2015; 88: 52-56


    Studies have shown that healthcare professionals (HCPs) display a 16-55% error rate in adherence to the Neonatal Resuscitation Program (NRP) algorithm. The aim of this study was to evaluate adherence to the Neonatal Resuscitation Program algorithm by subjects working from memory as compared to subjects using a decision support tool that provides auditory and visual prompts to guide implementation of the Neonatal Resuscitation Program algorithm during simulated neonatal resuscitation.Healthcare professionals (physicians, nurse practitioners, obstetrical/neonatal nurses) with a current NRP card were randomized to the control or intervention group and performed three simulated neonatal resuscitations. The scenarios were evaluated for the initiation and cessation of positive pressure ventilation (PPV) and chest compressions (CC), as well as the frequency of FiO2 adjustment. The Wilcoxon rank sum test was used to compare a score measuring the adherence of the control and intervention groups to the Neonatal Resuscitation Program algorithm.Sixty-five healthcare professionals were recruited and randomized to the control or intervention group. Positive pressure ventilation was performed correctly 55-80% of the time in the control group vs. 94-95% in the intervention group across all three scenarios (p<0.0001). Chest compressions were performed correctly 71-81% of the time in the control group vs. 82-93% in the intervention group in the two scenarios in which they were indicated (p<0.0001). FiO2 was addressed three times more frequently in the intervention group compared to the control group (p<0.001).Healthcare professionals using a decision support tool exhibit significantly fewer deviations from the Neonatal Resuscitation Program algorithm compared to those working from memory alone during simulated neonatal resuscitation.

    View details for DOI 10.1016/j.resuscitation.2014.12.016

    View details for PubMedID 25555358

  • Referral of Very Low Birth Weight Infants to High-Risk Follow-Up at Neonatal Intensive Care Unit Discharge Varies Widely across California. journal of pediatrics Hintz, S. R., Gould, J. B., Bennett, M. V., Gray, E. E., Kagawa, K. J., Schulman, J., Murphy, B., Villarin-Duenas, G., Lee, H. C. 2015; 166 (2): 289-295


    To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative.Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral.In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ? 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment.There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

    View details for DOI 10.1016/j.jpeds.2014.10.038

    View details for PubMedID 25454311

  • Regional variation in antenatal corticosteroid use: a network-level quality improvement study. Pediatrics Profit, J., Goldstein, B. A., TAMARESIS, J., Kan, P., Lee, H. C. 2015; 135 (2): e397-404


    Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions.We undertook cross-sectional analysis of 33?610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect.From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance.We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.

    View details for DOI 10.1542/peds.2014-2177

    View details for PubMedID 25601974

  • Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G. M., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)


    Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15?779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

    View details for DOI 10.1001/jamapediatrics.2014.3676

    View details for PubMedID 25642906

  • Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


    There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30?566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

    View details for DOI 10.1001/jamapediatrics.2014.2085

    View details for PubMedID 25383940

  • Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation Perlman, J. M., Wyllie, J. n., Kattwinkel, J. n., Wyckoff, M. H., Aziz, K. n., Guinsburg, R. n., Kim, H. S., Liley, H. G., Mildenhall, L. n., Simon, W. M., Szyld, E. n., Tamura, M. n., Velaphi, S. n. 2015; 132 (16 Suppl 1): S204?41

    View details for DOI 10.1161/CIR.0000000000000276

    View details for PubMedID 26472855

  • Protocol for delivery room management of hydrops Neonatology: Clinical Practice and Procedures Gupta, A., Lee, H. C. edited by Stevenson, D. K., Cohen, R. S., Sunshine, P. McGraw Hill Education. 2015: 999?1004
  • The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. Journal of perinatology : official journal of the California Perinatal Association Griffin, I. J., Lee, H. C., Profit, J. n., Tancedi, D. J. 2015


    Objective:Survival of preterm and very low birth weight (VLBW) infants has steadily improved. However, the rates of mortality and morbidity among the very smallest infants are poorly characterized.Study Design:Data from the California Perinatal Quality Care Collaborative for the years 2005 to 2012 were used to compare the mortality and morbidity of profoundly low birth weight (ProLBW, birth weight 300 to 500?g) and profoundly small for gestational age (ProSGA, <1st centile for weight-for-age) infants with very low birth weight (VLBW, birth weight 500 to 1500?g) and appropriate for gestational age (AGA, 5th to 95th centile for weight-for-age) infants, respectively.Result:Data were available for 44?561 neonates of birth weight <1500?g. Of these, 1824 were ProLBW and 648 were ProSGA. ProLBW and ProSGA differed in their antenatal risk factors from the comparison groups and were less likely to receive antenatal steroids or to be delivered by cesarean section. Only 14% of ProSGA and 21% of ProLBW infants survived to hospital discharge, compared with >80% of AGA and VLBW infants. The largest increase in mortality in ProSGA and ProLBW infants occurred prior to 12?h of age, and most mortality happened in this time period. Survival of the ProLBW and ProSGA infants was positively associated with higher gestational age, receipt of antenatal steroids, cesarean section delivery and singleton birth.Conclusion:Survival of ProLBW and ProSGA infants is uncommon, and survival without substantial morbidity is rare. Survival is positively associated with receipt of antenatal steroids and cesarean delivery.Journal of Perinatology advance online publication, 15 January 2015; doi:10.1038/jp.2014.233.

    View details for PubMedID 25590218

  • Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study PEDIATRICS Lee, H. C., Powers, R. J., Bennett, M. V., Finer, N. N., Halamek, L. P., Nisbet, C., Crockett, M., Chance, K., Blackney, D., von Koehler, C., Kurtin, P., Sharek, P. J. 2014; 134 (5): E1378-E1386


    There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects.This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support.There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12?528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%).Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices.

    View details for DOI 10.1542/peds.2014-0863

    View details for Web of Science ID 000344385900014

  • Hypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy in the State of California. journal of pediatrics Kracer, B., Hintz, S. R., Van Meurs, K. P., Lee, H. C. 2014; 165 (2): 267-273


    To characterize the implementation of hypothermia for neonatal hypoxic ischemic encephalopathy (HIE) in a population-based cohort.Using the California Perinatal Quality Care Collaborative and California Perinatal Transport System linked 2010-2012 datasets, we categorized infants ?36 weeks' gestation with HIE as receiving hypothermia or normothermia. Sociodemographic and clinical factors were compared, and multivariable logistic regression was used to determine factors associated with hypothermia therapy.There were 238 reported encephalopathy cases in 2010, 280 in 2011, and 311 in 2012. Hypothermia therapy use in newborns with HIE increased from 59% to 73% across the study period, mainly occurring in newborns with mild or moderate encephalopathy. A total of 36 centers provided hypothermia and cared for 94% of infants, with the remaining 6% being cared for at one of 25 other centers. Of the centers providing hypothermia, 12 centers performed hypothermia therapy to more than 20 patients during the 3-year study period, and 24 centers cared for <20 patients receiving hypothermia. In-hospital mortality was 13%, which primarily was associated with the severity of encephalopathy.Our findings highlight an opportunity to explore practice-site variation and to develop quality improvement interventions to assure consistent evidence-based care of term infants with HIE and appropriate application of hypothermia therapy for eligible newborns.

    View details for DOI 10.1016/j.jpeds.2014.04.052

    View details for PubMedID 24929331

    View details for PubMedCentralID PMC4111956

  • Caesarean delivery for twin gestation at 32-38 weeks does not lead to improved clinical outcomes for neonates or mothers. Evidence-based medicine Lee, H. C., Blumenfeld, Y. J. 2014; 19 (3): 119-?

    View details for DOI 10.1136/eb-2013-101655

    View details for PubMedID 24361755

  • Emergency Department Visits in the Neonatal Period in the United States PEDIATRIC EMERGENCY CARE Lee, H. C., Bardach, N. S., Maselli, J. H., Gonzales, R. 2014; 30 (5): 315-318


    This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

    View details for DOI 10.1097/PEC.0000000000000120

    View details for Web of Science ID 000335749100004

    View details for PubMedID 24759490

  • The impact of an intervention package promoting effective neonatal resuscitation training in rural China. Resuscitation Xu, T., Wang, H., Gong, L., Ye, H., Yu, R., Wang, D., Wang, L., Feng, Q., Lee, H. C., McGowan, J. E., Zhang, T. 2014; 85 (2): 253-259


    To evaluate an intervention package promoting effective neonatal resuscitation training at county level hospitals across China.The intervention package was implemented across 4 counties and included expert seminars, training workshops, establishment of hospital-based resuscitation teams, and supervision of training by national and provincial instructors. Upon completing the activities, a survey was conducted in all county hospitals in the 4 intervention counties and 4 randomly selected control counties. Data on healthcare providers' knowledge and self-confidence, and incidence of deaths from birth asphyxia from 2009 to 2011 in all hospitals were collected and compared between the two groups.Eleven intervention and eleven control hospitals participated in the evaluation, with 97 and 87 health providers, respectively, completing the questionnaire survey. Over 90% of intervention hospitals had implemented neonatal resuscitation related practice protocols, while in control hospitals the proportion was less than 55%. The average knowledge scores of health providers in the intervention and control counties taking a written exam were 9.2±1.2 and 8.4±1.5, respectively (P<0.001) out of maximum possible score of 10, and the average self-confidence scores were 57.3±2.5 and 54.1±8.2, respectively (P<0.001). Incidence of birth asphyxia (defined as 1-min Apgar score?7) decreased from 8.8% to 6.0% (P<0.001) in the intervention counties, and asphyxia-related deaths in the delivery room decreased from 27.6 to 5.0 per 100,000 (P=0.076). There was no difference over time in asphyxia rates for the control counties.The intervention has not only improved skills of health providers, decreased the mortality and morbidity of birth asphyxia, but also resulted in effective implementation of guidelines and protocols within hospitals.

    View details for DOI 10.1016/j.resuscitation.2013.10.020

    View details for PubMedID 24176723

  • Oral misoprostol versus vaginal dinoprostone for labor induction in nulliparous women at term. Journal of perinatology Faucett, A. M., Daniels, K., Lee, H. C., El-Sayed, Y. Y., Blumenfeld, Y. J. 2014; 34 (2): 95-99


    Objective:To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Study design:Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24?h, mode of delivery and maternal and fetal outcomes.Result:A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9?h, P<0.0001) and were more likely to deliver vaginally in <24?h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Conclusion:Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.

    View details for DOI 10.1038/jp.2013.133

    View details for PubMedID 24157494

  • Incidence and Impact of CMV Infection in Very Low Birth Weight Infants. Pediatrics Turner, K. M., Lee, H. C., Boppana, S. B., Carlo, W. A., Randolph, D. A. 2014


    Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants.VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed.Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs 9%, P < .0001) and confirmed at follow-up (83% vs 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs 25%, P < .0001) and adverse developmental motor outcomes (43% vs 9%, P = .02). Acquired CMV was not associated with any adverse outcomes.Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.

    View details for DOI 10.1542/peds.2013-2217

    View details for PubMedID 24488749

  • Maternal determinants of breast milk feeding in a level III neonatal intensive care unit Journal of Neonatal Nursing Martin-Anderson, S., Lee, H. C. 2014; 21 (4): 150-156
  • Outcomes of extremely preterm infants after delivery room cardiopulmonary resuscitation in a population-based cohort. Journal of perinatology : official journal of the California Perinatal Association Handley, S. C., Sun, Y. n., Wyckoff, M. H., Lee, H. C. 2014


    Objective:To describe the relationship of delivery room cardiopulmonary resuscitation (DR-CPR) to short-term outcomes of extremely preterm infants.Study design:This was a cohort study of 22 to 27+6/7 weeks gestational age (GA) infants during 2005 to 2011. DR-CPR was defined as chest compressions and/or epinephrine administration. Multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) associated with DR-CPR; analysis was stratified by GA.Result:Of the 13?758 infants, 856 (6.2%) received DR-CPR. Infants 22 to 23+6/7 weeks receiving DR-CPR had similar outcomes to non-recipients. Infants 24 to 25+6/7 weeks receiving DR-CPR had more severe intraventricular hemorrhage (OR 1.36, 95% CI 1.07, 1.72). Infants 26 to 27+6/7 weeks receiving DR-CPR were more likely to die (OR 1.81, 95% CI 1.30, 2.51) and have intraventricular hemorrhage (OR 2.10, 95% CI 1.56, 2.82). Adjusted hospital DR-CPR rates varied widely (median 5.7%).Conclusion:Premature infants receiving DR-CPR had worse outcomes. Mortality and morbidity varied by GA.Journal of Perinatology advance online publication, 18 December 2014; doi:10.1038/jp.2014.222.

    View details for PubMedID 25521563

  • Evaluating and Improving the Safety and Quality of Neonatal Intensive Care Fanaroff and Martin's Neonatal-Perinatal Medicine Profit, J., Lee, H. C., Gould, J. B., Horbar, J. D. edited by Martin, R., Fanaroff, A., Walsh, M. Elsevier. 2014; 10: 59?88
  • Consequences of the Affordable Care Act for Sick Newborns. Pediatrics Profit, J. n., Wise, P. H., Lee, H. C. 2014

    View details for PubMedID 25311609

  • Neurodevelopmental Outcomes for Infants Born With Congenital Heart Disease NeoReviews Chock, V., Lee, H. C. 2014; 15 (8): e344-53

    View details for DOI 10.1542/neo.15-8-e344

  • Accounting for variation in length of NICU stay for extremely low birth weight infants. Journal of perinatology Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B. 2013; 33 (11): 872-876


    Objective:To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.Study Design:We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000?g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.Results:There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).Conclusion:Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

    View details for DOI 10.1038/jp.2013.92

    View details for PubMedID 23949836

    View details for PubMedCentralID PMC3815522

  • Measuring hospital quality using pediatric readmission and revisit rates. Pediatrics Bardach, N. S., Vittinghoff, E., Asteria-Peñaloza, R., Edwards, J. D., Yazdany, J., Lee, H. C., Boscardin, W. J., Cabana, M. D., Dudley, R. A. 2013; 132 (3): 429-436


    To assess variation among hospitals on pediatric readmission and revisit rates and to determine the number of high- and low-performing hospitals.In a retrospective analysis using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project with revisit linkages available, we identified pediatric (ages 1-20 years) visits with 1 of 7 common inpatient pediatric conditions (asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy). For each condition, we calculated rates of all-cause readmissions and rates of revisits (readmission or presentation to the emergency department) within 30 and 60 days of discharge. We used mixed logistic models to estimate hospital-level risk-standardized 30-day revisit rates and to identify hospitals that had performance statistically different from the group mean.Thirty-day readmission rates were low (<10.0%) for all conditions. Thirty-day rates of revisit to the inpatient or emergency department setting ranged from 6.2% (appendicitis) to 11.0% (mood disorders). Study hospitals (n = 958) had low condition-specific visit volumes (37.0%-82.8% of hospitals had <25 visits). The only condition with >1% of hospitals labeled as different from the mean on 30-day risk-standardized revisit rates was mood disorders (4.2% of hospitals [n = 15], range of hospital performance 6.3%-15.9%).We found that when comparing hospitals' performances to the average, few hospitals that care for children are identified as high- or low-performers for revisits, even for common pediatric diagnoses, likely due to low hospital volumes. This limits the usefulness of condition-specific readmission or revisit measures in pediatric quality measurement.

    View details for DOI 10.1542/peds.2012-3527

    View details for PubMedID 23979094

    View details for PubMedCentralID PMC3876751

  • Developing Physician-Scientists in the Fields of Neonatology and Pediatric Critical Care Medicine: An Effort to Formulate a Departmental Policy JOURNAL OF PEDIATRICS Oishi, P. E., Klein, O. D., Keller, R. L. 2013; 163 (3): 616-?

    View details for DOI 10.1016/j.jpeds.2013.05.047

    View details for Web of Science ID 000323985300001

    View details for PubMedID 23973233

  • The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study PLOS ONE Acosta, C. D., Knight, M., Lee, H. C., Kurinczuk, J. J., Gould, J. B., Lyndon, A. 2013; 8 (7)


    To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI?=?9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR?=?1.29; ?35 years: aOR?=?1.41), had ?high-school education (aOR?=?1.63), public/no-insurance (aOR?=?1.22) or a cesarean section (primary: aOR?=?1.99; repeat: aOR?=?1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI?=?4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR?=?2.09), Asian (aOR?=?1.59), Hispanic (aOR?=?1.42), had public/no-insurance (aOR?=?1.52), delivered in hospitals with <1,000 births/year (aOR?=?1.93), were primiparous (aOR?=?2.03), had a multiple birth (aOR?=?3.5), diabetes (aOR?=?1.47), or chronic hypertension (aOR?=?8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR?=?3.72; aOR?=?4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI?=?17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI?=?40.8-74.4).The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

    View details for DOI 10.1371/journal.pone.0067175

    View details for Web of Science ID 000321341000034

    View details for PubMedID 23843991

    View details for PubMedCentralID PMC3699572

  • Perspectives on Promoting Breastmilk Feedings for Premature Infants During a Quality Improvement Project BREASTFEEDING MEDICINE Lee, H. C., Martin-Anderson, S., Lyndon, A., Dudley, R. A. 2013; 8 (2): 176-180


    This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.

    View details for DOI 10.1089/bfm.2012.0056

    View details for Web of Science ID 000317472700007

    View details for PubMedID 23186387

    View details for PubMedCentralID PMC3616405

  • The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: implications for delivery of care, training and technology design. Resuscitation Chitkara, R., Rajani, A. K., Oehlert, J. W., Lee, H. C., Epi, M. S., Halamek, L. P. 2013; 84 (3): 369-372


    Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than ± 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.

    View details for DOI 10.1016/j.resuscitation.2012.07.035

    View details for PubMedID 22925993

  • Hospital-wide breastfeeding rates vs. breastmilk provision for very-low-birth-weight infants ACTA PAEDIATRICA Lee, H. C., Jegatheesan, P., Gould, J. B., Dudley, R. A. 2013; 102 (3): 268-272


    To investigate the relationship between breastmilk feeding in very-low-birth-weight infants in the neonatal intensive care unit and breastmilk feeding rates for all newborns by hospital.This was a cross-sectional study of 111 California hospitals in 2007 and 2008. Correlation coefficients were calculated between overall hospital breastfeeding rates and breastmilk feeding rates of very-low-birth-weight infants. Hospitals were categorized in quartiles by crude and adjusted very-low-birth-weight infant rates to compare rankings between measures.Correlation between breastmilk feeding rates of very-low-birth-weight infants and overall breastfeeding rates varied by neonatal intensive care unit level of care from 0.13 for intermediate hospitals to 0.48 for regional hospitals. For hospitals categorized in the top quartile according to overall breastfeeding rate, only 46% were in the top quartile for both crude and adjusted very-low-birth-weight infant rates. On the other hand, when considering the lowest quartile for overall breastfeeding hospitals, three of 27 (11%) actually were performing in the top quartile of performance for very-low-birth-weight infant rates.Reporting hospital overall breastfeeding rates and neonatal intensive care unit breastmilk provision rates separately may give an incomplete picture of quality of care.

    View details for DOI 10.1111/apa.12096

    View details for Web of Science ID 000314656600022

    View details for PubMedID 23174012

    View details for PubMedCentralID PMC3566354

  • "Breastfeeding" by Feeding Expressed Mother's Milk PEDIATRIC CLINICS OF NORTH AMERICA Flaherman, V. J., Lee, H. C. 2013; 60 (1): 227-?


    This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.

    View details for DOI 10.1016/j.pcl.2012.10.003

    View details for Web of Science ID 000313137500012

    View details for PubMedID 23178067

  • Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial BMJ QUALITY & SAFETY Chitkara, R., Rajani, A. K., Lee, H. C., Hansen, S. F., Halamek, L. P. 2013; 22 (2): 124-129


    To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.

    View details for DOI 10.1136/bmjqs-2012-001336

    View details for PubMedID 23112286

  • A Quality Improvement Project to Increase Breast Milk Use in Very Low Birth Weight Infants PEDIATRICS Lee, H. C., Kurtin, P. S., Wight, N. E., Chance, K., Cucinotta-Fobes, T., Hanson-Timpson, T. A., Nisbet, C. C., Rhine, W. D., Risingsun, K., Wood, M., Danielsen, B. H., Sharek, P. J. 2012; 130 (6): E1679-E1687


    To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

    View details for DOI 10.1542/peds.2012-0547

    View details for Web of Science ID 000314802000033

    View details for PubMedID 23129071

    View details for PubMedCentralID PMC3507251

  • Utilization of available prenatal screening and diagnosis: effects of the California screen program JOURNAL OF PERINATOLOGY Blumenfeld, Y. J., Taylor, J., Lee, H. C., Hudgins, L., Sung, J. F., El-Sayed, Y. Y. 2012; 32 (12): 907-912


    In 2009, the California Genetic Disease Branch introduced an aneuploidy screening program allowing Medi-Cal (state insured) patients access to state-sponsored first-trimester screening. The objective of this study was to assess the effect of greater access to prenatal screening on available resources at a single center.Data of prenatal screening and diagnostic procedures performed 4 months before the introduction of the program were compared with those of 12 months following the introduction.Between December 2008 and March 2010, 7689 women underwent first trimester screening, 1286 underwent amniocentesis and 398 underwent chorionic villus sampling. When a comparison was made between the 4 months before and the 12 months after the program's introduction, a greater number of nuchal translucency (NT) examinations was seen to have been performed (384 per month vs 513 per month, P=0.001). Prenatal diagnostic procedures did not increase, but a greater proportion was performed for positive screen results.Introduction of the California screening program was associated with increased NT procedures and fewer invasive procedures for advanced maternal age.

    View details for DOI 10.1038/jp.2012.8

    View details for Web of Science ID 000311831700002

    View details for PubMedID 22402484

  • Maternal morbidity during childbirth hospitalization in California JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Lyndon, A., Lee, H. C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2012; 25 (12): 2529-2535


    To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization.Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models.The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity.Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

    View details for DOI 10.3109/14767058.2012.710280

    View details for Web of Science ID 000311678300011

    View details for PubMedID 22779781

    View details for PubMedCentralID PMC3642201

  • Factors Associated with Failure to Screen Newborns for Retinopathy of Prematurity JOURNAL OF PEDIATRICS Bain, L. C., Dudley, R. A., Gould, J. B., Lee, H. C. 2012; 161 (5): 819-823


    To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed.We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening.Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings.Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population.

    View details for DOI 10.1016/j.jpeds.2012.04.020

    View details for Web of Science ID 000310370600013

    View details for PubMedID 22632876

    View details for PubMedCentralID PMC3470784

  • Intestinal malrotation and catastrophic volvulus in infancy. journal of emergency medicine Lee, H. C., Pickard, S. S., Sridhar, S., Dutta, S. 2012; 43 (1): e49-51


    Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.We performed a 7-year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.Although most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients' symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.

    View details for DOI 10.1016/j.jemermed.2011.06.135

    View details for PubMedID 22325550

    View details for PubMedCentralID PMC3351570

  • Clinician Perspectives on Barriers to and Opportunities for Skin-to-Skin Contact for Premature Infants in Neonatal Intensive Care Units BREASTFEEDING MEDICINE Lee, H. C., Martin-Anderson, S., Dudley, R. A. 2012; 7 (2): 79-84


    Our objective was to investigate key factors in promoting skin-to-skin contact (STSC) in the neonatal intensive care unit (NICU).As part of a California Perinatal Quality Care Collaborative on improving nutrition and promoting breastmilk feeding of premature infants, a multidisciplinary group of representatives from 11 hospitals discussed the progress and barriers in pursuing the project. A key component of the collaborative project was promotion of STSC. Sessions were audio-recorded, transcribed, and assessed using qualitative research methods with the aid of Atlas Ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Two primary investigators studied the transcripts for themes related to STSC. Using an iterative approach, selected themes were explored, and representative quotes were selected.Barriers to promoting STSC fell into broad themes of implementation, institutional, and familial factors. The main challenge identified in implementation was defining a clinically stable eligible population of patients. Key institutional factors were education and motivation of staff. Familial factors involved facilitation and sustained motivation of mothers. In response to these barriers, opportunities for promoting STSC were enacted or suggested by the group, including defining clinical stability for eligibility, facilitating documentation, strategies to increase parent and staff education and motivation, and encouraging maternal visitation and comfort.Our findings may be useful for institutions seeking to develop policies and strategies to increase STSC and breastmilk feeding in their NICUs.

    View details for DOI 10.1089/bfm.2011.0004

    View details for Web of Science ID 000302777000003

    View details for PubMedID 22011130

    View details for PubMedCentralID PMC3317520

  • Trends in Cesarean Delivery for Twin Births in the United States 1995-2008 OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B., Boscardin, W. J., El-Sayed, Y. Y., Blumenfeld, Y. J. 2011; 118 (5): 1095-1101


    To estimate trends and risk factors for cesarean delivery for twins in the United States.This was a cross-sectional study in which we calculated cesarean delivery rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean delivery rates by year and for vertex compared with breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.Cesarean delivery rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5%-92.1%) and the vertex twin category (45.1%-68.2%). The relative increase in the cesarean delivery rate for preterm and term neonates was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04-1.05).Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.

    View details for DOI 10.1097/AOG.0b013e3182318651

    View details for Web of Science ID 000296292600018

    View details for PubMedID 22015878

    View details for PubMedCentralID PMC3202294

  • The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Lee, H. C., Chien, A. T., Bardach, N. S., Clay, T., Gould, J. B., Dudley, R. A. 2011; 165 (5): 429-434


    To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings.Cross-sectional study based on risk-adjusted nosocomial infection rates.NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008.One hundred twenty-six California NICUs and 10 487 VLBW infants.Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years.Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the ? statistic.Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89.The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.

    View details for Web of Science ID 000290113500009

    View details for PubMedID 21536958

  • Hypothermia in very low birth weight infants: distribution, risk factors and outcomes JOURNAL OF PERINATOLOGY Miller, S. S., Lee, H. C., Gould, J. B. 2011; 31: S49-S56


    The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria.A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression.In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death.Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

    View details for DOI 10.1038/jp.2010.177

    View details for Web of Science ID 000289236900008

    View details for PubMedID 21448204

  • Improved outcomes with a standardized feeding protocol for very low birth weight infants JOURNAL OF PERINATOLOGY McCallie, K. R., Lee, H. C., Mayer, O., Cohen, R. S., Hintz, S. R., Rhine, W. D. 2011; 31: S61-S67


    The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes.Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20?ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160?ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points.Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120?ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160?ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03).These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.

    View details for DOI 10.1038/jp.2010.185

    View details for Web of Science ID 000289236900010

    View details for PubMedID 21448207

  • Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality-Improvement Model PEDIATRICS Wirtschafter, D. D., Powers, R. J., Pettit, J. S., Lee, H. C., Boscardin, W. J., Subeh, M. A., Gould, J. B. 2011; 127 (3): 419-426


    To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals.The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

    View details for DOI 10.1542/peds.2010-1449

    View details for Web of Science ID 000287845400043

    View details for PubMedID 21339273

    View details for PubMedCentralID PMC3387911

  • Antenatal Steroid Administration for Premature Neonates in California OBSTETRICS AND GYNECOLOGY Lee, H. C., Lyndon, A., Blumenfeld, Y. J., Dudley, R. A., Gould, J. B. 2011; 117 (3): 603-609


    To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term.Clinical data for premature neonates born in 2005?2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors.Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005?2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999? 2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001).A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

    View details for DOI 10.1097/AOG.0b013e31820c3c9b

    View details for Web of Science ID 000287649400013

    View details for PubMedID 21446208

    View details for PubMedCentralID PMC3072287

  • Translating evidence into practice, policy, and public health in perinatal medicine NeoReviews Lee, H. C., Dudley, R. A., Gonzales, R. 2011; 12 (8): e431-438

    View details for DOI 10.1542/neo.12-8-e431

  • Breast-milk feeding of very low birth weight infants as a function of hospital demographics Journal of Perinatology Lee, H. C., Gould, J. B., Martin-Anderson, S., Dudley, R. A. 2011; 31 (Supplement): S82

    View details for DOI 10.1038/jp.2010.179

  • Hematologic abnormalities and jaundice Rudolph's Pediatrics Lee, H. C., Madan, A. McGraw-Hill Medical Publishing Co.. 2011; 22nd ed.
  • Transition to Oral Feeding in Preterm Infants NeoReviews Sridhar, S., Arguello, S., Lee, H. C. 2011; 12 (8): e141-147

    View details for DOI 10.1542/neo.12-3-e141

  • Low Apgar score and mortality in extremely preterm neonates born in the United States ACTA PAEDIATRICA Lee, H. C., Subeh, M., Gould, J. B. 2010; 99 (12): 1785-1789


    To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates.Infant birth and death certificate data from the US National Center for Health Statistics for 2001-2002 were analysed. Primary outcome was 28-day mortality for 690, 933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and 5-min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age.Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks.? Low Apgar score was associated with increased mortality in premature neonates, including those at 24-28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.

    View details for DOI 10.1111/j.1651-2227.2010.01935.x

    View details for Web of Science ID 000283690300010

    View details for PubMedID 20626363

    View details for PubMedCentralID PMC2970674

  • Prediction of Death for Extremely Premature Infants in a Population-Based Cohort PEDIATRICS Lee, H. C., Green, C., Hintz, S. R., Tyson, J. E., Parikh, N. A., Langer, J., Gould, J. B. 2010; 126 (3): E644-E650


    Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

    View details for DOI 10.1542/peds.2010-0097

    View details for Web of Science ID 000281535700047

    View details for PubMedID 20713479

  • Ultrasound estimation of fetal weight in small for gestational age pregnancies JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Blumenfeld, Y. J., Lee, H. C., Pullen, K. M., Wong, A. E., Pettit, K., Taslimi, M. M. 2010; 23 (8): 790-793


    Approximately half of small for gestational age (SGA) cases are due to maternal or fetal pathology, and may result in significant neonatal morbidity and mortality. The estimated fetal weight (EFW) measurement is the cornerstone of ultrasonographic findings when diagnosing and managing SGA pregnancies. Our objective was to determine the ultrasound accuracy of EFW in SGA pregnancies.A retrospective chart review was performed of all pregnancies complicated by SGA from a single institution (Stanford University) over a 2-year-period (2004-2006). SGA was defined as EFW < or = 10%. 98 neonates whose last ultrasound for EFW occurred within 7 days of delivery were included in the study. The absolute differences between the EFW and birthweight (BW) were analyzed, and the absolute percent errors were calculated as (EFW - BW)/BW x 100. The mean absolute differences and mean absolute percent errors were analyzed across all gestational ages (GA) and EFWs using one-way analysis of variance.The mean absolute percent error for the entire cohort was 8.7% (+/-6.3%). There was no statistically significant difference in the mean absolute percent error across all GAs (<32 weeks, 32-36 weeks, >36 weeks), and EFWs (<1500 g, 1500-2000 g, >2000 g).Ultrasound measurement of EFW in SGA pregnancies is consistent across all GAs and EFW measurements.

    View details for DOI 10.3109/14767050903387052

    View details for Web of Science ID 000280592200006

    View details for PubMedID 19968588

  • A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS Lee, H. C., Chitkara, R., Halamek, L. P., Hintz, S. R. 2010; 157 (1): 158-U211


    To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.

    View details for DOI 10.1016/j.jpeds.2010.01.029

    View details for Web of Science ID 000278649200037

    View details for PubMedID 20304418

    View details for PubMedCentralID PMC2886184

  • Morbidity Risk at Birth for Asian Indian Small for Gestational Age Infants AMERICAN JOURNAL OF PUBLIC HEALTH Lee, H. C., Ramachandran, P., Madan, A. 2010; 100 (5): 820-822


    Whether the traditional definition of small for gestational age (SGA) is an appropriate marker of risk for populations that have relatively lower birthweight is unclear. We determined proportions of White and Asian Indian SGA infants and those admitted to the special care nursery. Compared with White infants, Asian Indian infants were more likely to be SGA (14.5% versus 2.7%) and more likely to be admitted to the special care nursery (20.7% versus 3.7%), suggesting that traditional definitions of SGA may be applicable as a marker of risk.

    View details for DOI 10.2105/AJPH.2009.165001

    View details for Web of Science ID 000276828800015

    View details for PubMedID 20299660

    View details for PubMedCentralID PMC2853612

  • Epidemiology of Breech Delivery TEXTBOOK OF PERINATAL EPIDEMIOLOGY Lee, H., Gould, J. B., Sheiner, E. 2010: 663?77
  • Factors Influencing Breast Milk versus Formula Feeding at Discharge for Very Low Birth Weight Infants in California JOURNAL OF PEDIATRICS Lee, H. C., Gould, J. B. 2009; 155 (5): 657-U94


    To investigate incidence and factors influencing breast milk feeding at discharge for very low birth weight infants (VLBW) in a population-based cohort.We used data from the California Perinatal Quality Care Collaborative to calculate incidence of breast milk feeding at hospital discharge for 6790 VLBW infants born in 2005-2006. Multivariable logistic regression was used to examine which sociodemographic and medical factors were associated with breast milk feeding. The impact of removing risk adjustment for race was examined.At initial hospital discharge, 61.1% of VLBW infants were fed breast milk or breast milk supplemented with formula. Breast milk feeding was more common with higher birth weight and gestational age. After risk adjustment, multiple birth was associated with higher breast milk feeding. Factors associated with exclusive formula feeding were Hispanic ethnicity, African American race, and no prenatal care. Hospital risk-adjusted rates of breast milk feeding varied widely (range 19.7% to 100%) and differed when race was removed from adjustment.A substantial number of VLBW infants were not fed breast milk at discharge. Specific groups may benefit from targeted interventions to promote breast milk feeding. There may be benefit to reporting risk-adjusted rates both including and excluding race in adjustment when considering quality improvement initiatives.

    View details for DOI 10.1016/j.jpeds.2009.04.064

    View details for Web of Science ID 000271570900014

    View details for PubMedID 19628218

  • Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis FERTILITY AND STERILITY Moayeri, S. E., Lee, H. C., Lathi, R. B., Westphal, L. M., Milki, A. A., Garber, A. M. 2009; 92 (2): 471-480


    To evaluate the cost effectiveness of laparoscopy for unexplained infertility.We performed a cost-effectiveness analysis using a computer-generated decision analysis tree. Data used to construct the mathematical model were extracted from the literature or obtained from our practice. We compared outcomes following four treatment strategies: [1] no treatment, [2] standard infertility treatment algorithm (SITA), [3] laparoscopy with expectant management (LSC/EM), and [4] laparoscopy with infertility therapy (LSC/IT). The incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analyses assessed the impact of varying base-case estimates.Academic in vitro fertilization practice.Computer-simulated patients assigned to one of four treatments.Fertility treatment or laparoscopy.Incremental cost-effectiveness ratios.Using base-case assumptions, LSC/EM was preferred (ICER =$128,400 per live-birth in U.S. dollars). Changing the following did not alter results: rates and costs of multiple gestations, penalty for high-order multiples, infertility treatment costs, and endometriosis prevalence. Outcomes were most affected by patient dropout from infertility treatments-SITA was preferred when dropout was less than 9% per cycle. Less important factors included surgical costs, acceptability of twins, and the effects of untreated endometriosis on fecundity.Laparoscopy is cost effective in the initial management of young women with infertility, particularly when infertility treatment dropout rates exceed 9% per cycle.

    View details for DOI 10.1016/j.fertnstert.2008.05.074

    View details for PubMedID 18722609

  • Changes in Attendance at Deliveries by Pediatric Residents 2000 to 2005 AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Rhee, C. J., Sectish, T. C., Hintz, S. R. 2009; 26 (2): 129-134


    We sought to determine if pediatric resident attendance at deliveries for newborn assessment and resuscitation had changed over the years at a training hospital. Data were abstracted from medical records of newborns discharged during the same 6-week periods for 5 consecutive academic years spanning a period before and after resident duty hour regulation changes were implemented. Names of personnel attending deliveries were noted in delivery records. The proportions of deliveries attended by any practitioner were compared by year, as well as the proportion of deliveries attended by practitioner type and training level. A total of 2666 delivery records were reviewed. The proportions of deliveries attended by any practitioner over the 5 years were similar, ranging from 43 to 49%. The proportion of deliveries attended by pediatric residents was highest at 51 to 57% from 2000 to 2002, declined to a low of 5% during 2002 to 2003, and rose to 20 to 23% during 2003 to 2005 ( P < 0.0001). The decrease in attendance by residents was compensated by an increase in attendance by hospitalists. At this training institution, pediatric resident attendance at deliveries declined substantially over recent years, likely due in part to resident duty hour regulations and increased use of hospitalists in roles previously held by residents.

    View details for DOI 10.1055/s-0028-1091395

    View details for Web of Science ID 000262934700006

    View details for PubMedID 18850515

  • A quality improvement project to improve admission temperatures in very low birth weight infants JOURNAL OF PERINATOLOGY Lee, H. C., Ho, Q. T., Rhine, W. D. 2008; 28 (11): 754-758


    To review the results of a quality improvement (QI) project to improve admission temperatures of very low birth weight inborn infants.The neonatal intensive care unit at Lucile Packard Children's Hospital underwent a QI project to address hypothermic preterm newborns by staff education and implementing processes such as polyethylene wraps and chemical warming mattresses. We performed retrospective chart review of all inborn infants with birth weight <1500 g during the 18 months prior to (n=134) and 15 months after (n=170) the implementation period. Temperatures were compared between periods. Multivariable logistic regression was used to account for potential confounding variables. We compared mortality rates and grade 3 or 4 intraventricular hemorrhage rates between periods.The mean temperature rose from 35.4 to 36.2 degrees C (P<0.0001) after the QI project. The improvement was consistent and persisted over a 15-month period. After risk adjustment, the strongest predictor of hypothermia was being born in the period before implementation of the QI project (odds ratio 8.12, 95% confidence interval 4.63, 14.22). Although cesarean delivery was a strong risk factor for hypothermia prior to the project, it was no longer significant after the project. There was no significant difference in death or intraventricular hemorrhage detected between periods.There was a significant improvement in admission temperatures after a QI project, which persisted beyond the initial implementation period. Although there was no difference in mortality or intraventricular hemorrhage rates, we did not have sufficient power to detect small differences in these outcomes.

    View details for DOI 10.1038/jp.2008.92

    View details for Web of Science ID 000260795100005

    View details for PubMedID 18580878

  • School Outcomes of Late Preterm Infants: Special Needs and Challenges for Infants Born at 32-to 36-Week Gestation OBSTETRICAL & GYNECOLOGICAL SURVEY Chyl, L. J., Lee, H. C., Hintz, S. R., Gould, J. B., Sutcliffe, T. L. 2008; 63 (11): 691?92
  • School outcomes of late preterm infants: Special needs and challenges for infants born at 32 to 36 weeks gestation JOURNAL OF PEDIATRICS Chyi, L. J., Lee, H. C., Hintz, S. R., Gould, J. B., Sutcliffe, T. L. 2008; 153 (1): 25-31


    Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants.A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared.LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels.Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.

    View details for DOI 10.1016/j.jpeds.2008.01.027

    View details for Web of Science ID 000257154800010

    View details for PubMedID 18571530

  • Predictors of adverse neonatal outcomes in pregnancies complicated by intrauterine growth restriction Blumenfeld, Y., Hunter, K., Lee, H., Pullen, K., Wong, A., Taslimi, M. LIPPINCOTT WILLIAMS & WILKINS. 2008: 57S
  • Ambiguous Genitalia in the Newborn NeoReviews Chi, C., Lee, H. C., Neely, E. K. 2008; 9 (2): e78-84

    View details for DOI 10.1542/neo.9-2-e78

  • Ultrasound accuracy of estimated fetal weight in pregnancies complicated by intra-uterine growth restriction Blumenfeld, Y., Lee, H., Pullen, K., Wong, A., Pettit, K., Taslimi, M. MOSBY-ELSEVIER. 2007: S59
  • Reply to McAdams and Milhoan JOURNAL OF PERINATOLOGY Lee, H. C., Silverman, N., Hintz, S. R. 2007; 27 (11): 735?36
  • Oropharyngeal atresia in a preterm infant: A case report and review of the literature INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Lee, H. C., O-Lee, T. J., Madan, A., Koltai, P. 2007; 71 (9): 1485-1489


    Oropharyngeal atresia is a rare and often fatal condition that presents soon after birth with severe respiratory distress. We present a case of a premature infant who initially was suspected to have tracheo-esophageal atresia due to prenatal ultrasound findings of polyhydramnios and absent stomach bubble, but was found instead to have oropharyngeal atresia and a complete persistent buccopharyngeal membrane. This case is the first described in which the patient was successfully intubated through a small slit in the persistent membrane.

    View details for DOI 10.1016/j.ijport.2007.05.026

    View details for PubMedID 17597231

  • Trends in mode of delivery of breech presentation over a 5-year period - Response JOURNAL OF PERINATOLOGY Lee, H. C., El-Sayed, Y. Y., Gould, J. B. 2007; 27 (7): 464?65
  • Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine JOURNAL OF PERINATOLOGY Lee, H. C., Silverman, N., Hintz, S. R. 2007; 27 (5): 291-296


    To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training.Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist.There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%).A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.

    View details for DOI 10.1038/

    View details for Web of Science ID 000246105400008

    View details for PubMedID 17363908

  • Postnatal cytomegalovirus infection from frozen breast milk in preterm, low birth weight infants PEDIATRIC INFECTIOUS DISEASE JOURNAL Lee, H. C., Enright, A., Benitz, W. E., Madan, A. 2007; 26 (3): 276-276

    View details for Web of Science ID 000245089900022

    View details for PubMedID 17484235

  • Delivery mode by race for breech presentation in the US JOURNAL OF PERINATOLOGY Lee, H. C., El-Sayed, Y. Y., Gould, J. B. 2007; 27 (3): 147-153


    To determine if there are differential cesarean delivery rates by race and other socio-demographic factors for women with breech infants.We calculated cesarean delivery rates for 186 727 White, African American, Hispanic and Asian women delivering breech singletons with gestational age 26 to 41 weeks born in 1999 and 2000 using data from the National Center for Health Statistics. Multivariable logistic regression was used to determine differences in mode of delivery by race, adjusting for socio-demographic and medical factors.Cesarean rates for breech were >80% in most gestational age groups. In 14 of 18 groups, Whites had higher cesarean delivery rates than African Americans. However, this finding did not persist after risk adjustment. Hispanics were more likely to deliver by cesarean delivery than African Americans and Whites.Breech singleton infants are predominantly born by cesarean delivery. Although African-American women with breech presentation have lower cesarean delivery rates than Whites, this difference is not present after adjusting for socio-demographic and medical factors. Hispanics were more likely to be delivered by cesarean delivery and this difference was amplified after risk adjustment. Asians had slightly lower cesarean rates after risk adjustment, but this varied widely according to Asian subgroup.

    View details for DOI 10.1038/

    View details for Web of Science ID 000244420900003

    View details for PubMedID 17314983

  • Mode of delivery, size for gestational age, and low apgar scores in vertex preterm infants. Lee, H. C., Gould, J. B. B C DECKER INC. 2007: S76
  • Mode of delivery, size for gestational age, and low apgar scores in vertex preterm infants. Lee, H. C., Gould, J. B. B C DECKER INC. 2007: S116?S117
  • Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status PEDIATRICS Lee, H. C., Gould, J. B. 2006; 118 (6): E1836-E1844


    The goal was to characterize the relationship between cesarean section delivery and death for preterm vertex neonates according to intrauterine growth.Maternal and infant data from the National Center for Health Statistics for 1999 and 2000 were analyzed. Neonates with gestational ages of 26 to 36 weeks were characterized as small for gestational age (<10th percentile) or appropriate for gestational age (10th to 90th percentile). Mortality rates at 28 days and relative risks were calculated for each gestational age group according to mode of delivery.Cesarean section rates were higher for small-for-gestational-age neonates compared with appropriate-for-gestational-age neonates, most prominently from 26 weeks to 32 weeks of gestation, at which small-for-gestational-age neonates had cesarean section rates of 50% to 67%, whereas appropriate-for-gestational-age neonates had rates of 22% to 38%. Small-for-gestational-age neonates at gestational ages of <31 weeks had increased survival rates associated with cesarean section, whereas small-for-gestational-age neonates at >33 weeks and appropriate-for-gestational-age neonates overall had decreased survival rates associated with cesarean section. After adjustment for sociodemographic and medical factors, the survival advantage for small-for-gestational-age neonates at gestational ages of 26 to 30 weeks persisted.Cesarean section delivery was associated with survival for preterm small-for-gestational-age neonates but not preterm appropriate-for-gestational-age neonates. We speculate that vaginal delivery may be particularly stressful for small-for-gestational-age neonates. We found no evidence that prematurity alone is a valid indication for cesarean section for preterm appropriate-for-gestational-age neonates.

    View details for DOI 10.1542/peds.2006-1327

    View details for Web of Science ID 000242478900081

    View details for PubMedID 17142505

  • Survival advantage associated with cesarean delivery in very low birth weight vertex neonates. Obstetrics and gynecology Lee, H. C., Gould, J. B. 2006; 107 (1): 97-105


    To identify the indications for and any survival advantage associated with very low birth weight (VLBW) neonates delivered by cesarean.Maternal and infant data from the National Center for Health Statistics linked birth/death data set for 1999 to 2000 were analyzed. Maternal conditions associated with cesarean delivery were compared among birth weight groups for vertex neonates. Birth weight-specific 28-day mortality rates and relative risks were calculated with 95% confidence intervals. Multivariate logistic regression was performed to adjust for other factors that may be associated with survival.Cesarean delivery occurred frequently, more than 40% in most VLBW birth weight groups. Conditions associated with cesarean delivery in VLBW vertex neonates differed from those seen in non-VLBW vertex neonates. A survival advantage was associated with cesarean delivery in the birth weight analysis up to 1,300 g (P < .05). This decreased mortality for VLBW neonates delivered by cesarean persisted after adjusting for other factors associated with mortality.Very low birth weight vertex neonates are often born by cesarean delivery and have different maternal risk profiles from non-VLBW vertex neonates born by this route. Neonatal mortality was decreased in VLBW neonates delivered by cesarean. Further study is warranted to determine whether this may be a causal relationship or a marker of quality of care.II-2.

    View details for PubMedID 16394046

  • Visual Diagnosis: A Newborn Who Has Everted Eyelids NeoReviews Lee HC 2004; 5 (9): e390
  • Visual Diagnosis: Poor Feeding and Emesis in a 1-day-old Male NeoReviews Lee, H. C., Woolf, K. 2004; 5 (11): e498
  • Crosslinked hemoglobin inhibits endothelium-dependent relaxations in isolated canine arteries GENERAL PHARMACOLOGY-THE VASCULAR SYSTEM Katusic, Z. S., Lee, H. C., Clambey, E. T. 1996; 27 (2): 239-244


    1. Several previous in vivo studies demonstrated that crosslinked hemoglobin is a potent vasoconstrictor capable of significantly increasing arterial blood pressure following systemic administration. The precise mechanisms underlying the vascular effects of crosslinked hemoglobin are not clear. The present study was designed to determine the effect of crosslinked hemoglobin on the endothelial L-arginine-nitric oxide biosynthesis pathway in isolated canine arteries. 2. Isolated femoral and renal arteries were suspended in organ chambers for isometric tension recordings. Endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187 were studied in the absence or in the presence of crosslinked hemoglobin or hemoglobin. A radioimmunoassay technique was used to determine levels of guanosine 3',5'-cyclic monophosphate (cyclic GMP) and adenosine 3',5'-cyclic monophosphate (cyclic AMP). 3. A nitric oxide synthase inhibitor L-NAME (10(-4)M) selectively inhibited endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187. The inhibitory effect of L-NAME was reversed by L-arginine (3 x 10(-4)M). Crosslinked hemoglobin (10(-7), 10(-6) and 10(-5)M) inhibited endothelium-dependent relaxations to acetylcholine (10(-9)-10(-5)M) or A23187 (10(-9)-10(-6)M). In the same concentration range, purified bovine hemoglobin exerted a similar inhibitory effect on relaxations mediated by activation of endothelial cells. Crosslinked hemoglobin (10(-6)M) significantly reduced basal production of cyclic GMP, but did not affect production of cyclic AMP. Acetylcholine (10(-6)M) stimulated production of cyclic GMP. This effect of acetylcholine was abolished in the presence of crosslinked hemoglobin. 4. These studies demonstrate that crosslinked hemoglobin impairs endothelium-dependent relaxations in isolated large conduit arteries. This effect appears to be mediated by the chemical antagonism of crosslinked hemoglobin against nitric oxide released from the endothelium. Inhibition of the endothelial L-arginine-nitric oxide biosynthesis pathway, with subsequent decrease of cyclic GMP in smooth muscle, may help to explain vasoconstrictor and pressor effects of crosslinked hemoglobin.

    View details for Web of Science ID A1996UD24400008

    View details for PubMedID 8919636

Footer Links:

Stanford Medicine Resources: