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Between-hospital variation in treatment and outcomes in extremely preterm infants
Matthew A Rysavy1, Lei Li, Edward F Bell
1From the Stead Family Department of Pediatrics (M.A.R., E.F.B., J.C.M., T.T.C., J.E.B.) and the Department of Epidemiology (M.A.R.), University of Iowa, Iowa City; the Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, NC (L.L.), and Rockville, MD (A.D.); Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA (S.R.H.); Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta (B.J.S.); Department of Pediatrics, Women and Infants' Hospital, Brown University, Providence, RI (B.R.V.); Department of Pediatrics, University of Alabama at Birmingham, Birmingham (W.A.C.); Department of Pediatrics, Wayne State University, Detroit (S.S.); Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland (M.C.W.); Department of Pediatrics, University of Texas Medical School at Houston, Houston (J.E.T.); Department of Pediatrics, Duke University, Durham, NC (C.M.C., P.B.S.); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD (R.D.H.).
Insights
Hospital treatment decisions for extremely preterm infants significantly impact survival rates. Differences in initiating active treatment explain between-hospital variations in outcomes for infants born at 22-24 weeks gestation.
Area of Science:
- Neonatal Medicine
- Perinatal Research
- Pediatric Outcomes
Background:
- Significant unexplained variation exists in outcomes for extremely preterm infants across hospitals.
- Hospital practices regarding initiation of active lifesaving treatment versus comfort care may contribute to outcome disparities.
Purpose of the Study:
- To investigate the association between hospital practices and outcomes in extremely preterm infants.
- To determine the extent to which between-hospital variation in active treatment initiation explains outcome variations.
Main Methods:
- A cohort of 4987 infants born before 27 weeks gestation without congenital anomalies was studied across 24 hospitals.
- Active treatment was defined as any potentially lifesaving intervention post-birth.
- Survival and neurodevelopmental impairment were assessed at 18-22 months corrected age in 4704 children.
Main Results:
- Rates of active treatment varied widely, from 22.1% at 22 weeks to 99.8% at 26 weeks gestation.
- Survival rates ranged from 5.1% at 22 weeks to 81.4% at 26 weeks gestation.
- Hospital active treatment rates explained 78% of survival variation for 22-23 week infants, but less for older gestations.
Conclusions:
- Hospital practices in initiating active treatment for infants born at 22-24 weeks gestation partially explain between-hospital outcome variations.
- These findings highlight the impact of clinical decision-making on survival and impairment in extremely preterm neonates.
Background:
Between-hospital variation in outcomes among extremely preterm infants is largely unexplained and may reflect differences in hospital practices regarding the initiation of active lifesaving treatment as compared with comfort care after birth.
Methods:
We studied infants born between April 2006 and March 2011 at 24 hospitals included in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Data were collected for 4987 infants born before 27 weeks of gestation without congenital anomalies. Active treatment was defined as any potentially lifesaving intervention administered after birth. Survival and neurodevelopmental impairment at 18 to 22 months of corrected age were assessed in 4704 children (94.3%).
Results:
Overall rates of active treatment ranged from 22.1% (interquartile range [IQR], 7.7 to 100) among infants born at 22 weeks of gestation to 99.8% (IQR, 100 to 100) among those born at 26 weeks of gestation. Overall rates of survival and survival without severe impairment ranged from 5.1% (IQR, 0 to 10.6) and 3.4% (IQR, 0 to 6.9), respectively, among children born at 22 weeks of gestation to 81.4% (IQR, 78.2 to 84.0) and 75.6% (IQR, 69.5 to 80.0), respectively, among those born at 26 weeks of gestation. Hospital rates of active treatment accounted for 78% and 75% of the between-hospital variation in survival and survival without severe impairment, respectively, among children born at 22 or 23 weeks of gestation, and accounted for 22% and 16%, respectively, among those born at 24 weeks of gestation, but the rates did not account for any of the variation in outcomes among those born at 25 or 26 weeks of gestation.
Conclusions:
Differences in hospital practices regarding the initiation of active treatment in infants born at 22, 23, or 24 weeks of gestation explain some of the between-hospital variation in survival and survival without impairment among such patients. (Funded by the National Institutes of Health.).
