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Published on: November 20, 2015
Perinatal Regionalization and Implications for Long-Term Health Outcomes in Cerebral Palsy
Corneliu Bolbocean1, Pia Wintermark2, Michael I Shevell2
11Robbins Institute for Health Policy and Leadership,Department of Economics,Baylor University,Waco,TX.
Insights
Higher levels of neonatal care at delivery did not significantly impact the risk of severe cerebral palsy (CP). This suggests the existing perinatal regionalization system in Quebec is efficient in managing severe CP outcomes.
Area of Science:
- Neonatal care
- Cerebral palsy research
- Perinatal regionalization
Background:
- Perinatal regionalization is known to improve neonatal outcomes.
- The impact of neonatal care levels on long-term cerebral palsy (CP) outcomes remains unclear.
- This study investigates the association between neonatal care level at birth and the risk of nonambulatory CP.
Purpose of the Study:
- To determine if the highest levels of neonatal care available at delivery affect the risk of developing nonambulatory cerebral palsy (CP).
- To evaluate the efficiency of a regionalized neonatal-perinatal system in preventing severe CP phenotypes.
Main Methods:
- Analysis of 360 children with CP from the Canadian CP Registry in Quebec, excluding postneonatal causes.
- Utilized propensity score matching and instrumental variables methods to adjust for case mix differences.
- Defined nonambulatory CP status using the Gross Motor Function Classification System (GMFCS levels IV and V).
Main Results:
- No significant association was found between the level of neonatal care at delivery and the risk of nonambulatory CP.
- Estimates indicated no statistically significant reduction in nonambulatory CP risk when comparing level II vs. I, or level III vs. I care.
- A slight, but statistically significant, increase in nonambulatory CP risk was observed when comparing level III vs. II care.
Conclusions:
- The level of neonatal care at the hospital of delivery is not associated with the risk of a nonambulatory CP phenotype.
- The Quebec regionalized neonatal-perinatal system appears to utilize resources efficiently, offering no additional marginal benefit in reducing severe CP outcomes.
- The success of the neonatal resuscitation program and effective referral systems likely contribute to consistent outcomes across different care levels.
Background:
Perinatal regionalization is linked to improved neonatal outcomes; however, the effects on long-term outcomes in cerebral palsy (CP) are not known. We estimate the effect of highest levels of neonatal care available at delivery on the risk of developing a nonambulatory CP status.
Methods:
Children with CP born in Quebec from the Canadian CP Registry excluding postneonatal causes were included (N=360). We estimate the effect of level of care available at delivery on risk of nonambulatory status among children with CP using propensity score matching and instrumental variables methods to adjust for differences in case mix among the three groups of hospitals. The outcome variable is an indicator for CP nonambulation assigned according to Gross Motor Function Classification System (levels IV and V). This study used data that predated therapeutic hypothermia in Quebec.
Results:
Propensity score estimates of change in the adjusted risk of having a nonambulatory CP status because of birth at level II versus level I is -0.081, 95% confidence interval (CI; -0.2182 to 0.0562); level III versus level I is -0.072 95% CI (-0.225 to 0.08), and level III versus level II is 0.157 95% CI (0.027 to 0.286).
Conclusions:
Differences in levels of neonatal care available at hospital where the delivery was carried out are not associated with the risk of a nonambulatory CP phenotype. This suggests that level of care and associated medical technology within the Quebec regionalized neonatal-perinatal system is used efficiently because it does not offer any further marginal benefit in the reduction of severe CP outcomes. The system works well as it is, which is supportive of the perinatal regionalization. The success of the neonatal resuscitation program and referral of high-risk births to regional hospitals with sufficient obstetric and perinatal competence and resources may contribute to this lack of variability.
