Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, STATE, Policy/Guideline (State), Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital)

Intervention Description: To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001–2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.

Intervention Results: Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting.

Conclusion: Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

Study Design: Time trend analysis

Setting: All Arkansas hospitals Five level III hospitals from 2001- 2005, six in 2006

Population of Focus: Infants born at <35 weeks GA

Data Source: Data from Medicaid claims for pregnancy linked to birth certificates for women covered by Medicaid in Arkansas

Sample Size: Total (n= 5,150) 2001 (n= 812) 2002 (n= 1,105) 2003 (n= 824) 2004 (n= 824) 2005 (n= 887) 2006 (n= 698) Infants born at <35 weeks GA

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Follow-Up Given On Transferred Patients, STATE, Perinatal Committees/Councils, NICU Bed Registry/Electronic Bulletin Board

Intervention Description: To determine whether perinatal care in southwestern Ontario is regionalized, to identify trends over time in referral patterns, to quantify trends in perinatal death rates and to identify trends in perinatal death rates that give evidence of regionalization.

Intervention Results: Between 1982 and 1985 the antenatal transfer rate increased from 2.2% to 2.8% (p less than 0.003). The proportion of births of infants weighing 500 to 1499 g increased from 49% to 69% at the level III hospital. The neonatal transfer rate increased from 26.2% to 47.9% (p less than 0.05) for infants in this birth-weight category and decreased from 10.2% to 7.1% (p less than 0.03) for infants weighing 1500 to 2499 g. The death rate among infants of low birth weight was lowest among those born at the level III centre and decreased at all centres between 1982 and 1985.

Conclusion: Perinatal care in southwestern Ontario is regionalized and not centralized; regionalization in southwestern Ontario increased between 1982 and 1985.

Study Design: QE: pretest-posttest

Setting: Southwestern Ontario One level III, one modified level III and 30 level II or I

Population of Focus: Births greater than 500 gm

Data Source: Data obtained from hospital delivery room books and for 31 of the 32 hospitals, from hospital charts of women and neonates.

Sample Size: Pretest: 1.17% (n= 194) Posttest: 1.31% (n= 211) Infants born weighing 500-1499 gm

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital), STATE, Policy/Guideline (State)

Intervention Description: Telemedicine has been used successfully for medical care and education but it has never been utilized to modify patterns of delivery in an established state network.

Intervention Results: Medicaid deliveries at the regional perinatal centers increased from 23.8% before the intervention to 33% in neonates between 500 and 999 grams (p<0.05) and was unchanged in neonates between 2001-2500 grams.

Conclusion: Telemedicine is an effective way to translate evidence based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the regional perinatal centers.

Study Design: Time trend analysis

Setting: All Arkansas hospitals

Population of Focus: Infants born weighing 500-2499 gm. Data not given for other study years.

Data Source: Data from Arkansas Vital Statistics Data System linked with corresponding hospitalization records from Arkansas Hospital Discharge Data System.

Sample Size: Total (n= 12,258) 2001 (n= 2,965) 2004 (n= 3,154)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, Needs Assessment, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Agreement for Level III Hospital to Accept All Patients, STATE, Funding Support, Perinatal Committees/Councils

Intervention Description: A major objective was to develop and maintain a regionalized system of care. Such a system has been developed but differed from traditional systems by using regional level II centers. Iowa's low population density necessitated this modification.

Intervention Results: Level I hospitals currently manage low-risk patients and report very low mortality rates. Level II facilities receive high-risk referrals, but selective referral occurs since the tertiary center accounts for a disproportionate number of fetal and neonatal deaths, and births weighting less than 1500 g.

Conclusion: Other regions may benefit from similar approaches to development of regionalized systems of care and evaluation of the same.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 129 level I, 11 level II, and one level III hospital Posttest: 118 level I, 11 level II, and one level III hospital

Population of Focus: All infants born at ≥20 weeks GA and ≤1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 432) Posttest (n= 343)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, Needs Assessment, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Agreement for Level III Hospital to Accept All Patients, Perinatal Committees/Councils, STATE

Intervention Description: A voluntary system of regionalized perinatal health care was developed in Iowa to provide accessible services for a rural population.

Intervention Results: The intervention in Iowa focused on increasing both level III and level II VLBW births due to population density concerns in Iowa. Among all VLBW infants, there were changes in the birth location distribution. Of these infants, there was a statistically significant increase in percentage born in level III hospitals from 6.7% to 22.6% (p<0.05)1 and an increase in births in level II hospitals from 26.9% to 35.6%. The percentage born in level I centers decreased from 68.2% to 41.8%.

Conclusion: The concept of a mortality risk ratio (neonatal deaths/<1,500 gm live births) is suggested as a method of reviewing mortality data from the perspective of risks inherent in the population served.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 130 level I, 10 level II, and one level III hospital Posttest: 122 level I, 10 level II, and one level III hospital

Population of Focus: All live births <1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 440) Posttest (n= 402)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, Peer-Review of Provider Decisions, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Agreement for Level III Hospital to Accept All Patients, Medical Staff Integration

Intervention Description: Not available

Intervention Results: After the intervention, there was a statistically significant decrease in the number of VLBW infants born in a level II hospital (p<0.01).

Conclusion: Not available

Study Design: QE: pretest-posttest

Setting: Minnesota: Abbott-Northwestern/ Minneapolis Children’s Perinatal Center and Fairview-Southdale Hospital (Level II)

Population of Focus: All births at level II hospital

Data Source: Data source not provided.

Sample Size: Pretest (n= 2,573) Posttest (n= 2,722)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Maternal/In-Utero Transport Systems, INTER-HOSPITAL SYSTEMS, POPULATION-BASED SYSTEMS, Consultation Systems (Inter-Hospital Systems), Perinatal Committees/Councils, NICU Bed Registry/Electronic Bulletin Board

Intervention Description: The goal was to evaluate the impact of statewide coordinated changes in perinatal support and retrieval services on the outcomes of extremely premature births occurring outside perinatal centers in the state of New South Wales, Australia.

Intervention Results: There were 25% fewer nontertiary hospital live births (19.7% vs 14.9%) and more prenatal steroid use. Despite an 11.4% average annual increase in NICU admissions between the 2 epochs, fewer infants were outborn (12.0% vs 9.3%) and outborn mortality rates decreased significantly (39.4% vs 25.1%), particularly for those between 27 and 28 weeks of gestation. The overall improvement was equivalent to 1 extra survivor per 16 New South Wales births. There were also significantly fewer serious outcome morbidities in outborn infants during epoch 2, over the improvements in inborn infants.

Conclusion: Statewide coordinated strategies in reducing nontertiary hospital births and optimizing transport of outborn infants to perinatal centers have improved considerably the outcomes of extremely premature infants. These findings have vital implications for health outcomes and resource planning.

Study Design: QE: pretest-posttest

Setting: New South Wales, Australia hospitals Seven perinatal centers

Population of Focus: Infants born between 23+0 and 28+6 weeks GA who did not die before or during retrieval.

Data Source: Baseline population data for all births between 23 and 28 weeks GA obtained from the New South Wales Midwives Data Collection.

Sample Size: Pretest (n= 1,778) Posttest (n= 3,099)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), STATE, Policy/Guideline (State), Funding Support

Intervention Description: This report summarizes the evaluation of a national demonstration program of such regionalization that was funded by the Robert Wood Johnson Foundation (RWJF) in 1975.

Intervention Results: In both funded regions and comparison areas, the neonatal mortality rates decreased sharply over the decade of the 1970s. This decline was linked to shifts in the hospital of delivery that indicated antepartum risk identification and transfer of management of high-risk pregnancies to tertiary centers for delivery, a change in service pattern consistent with some aspects of regionalization. The centralization of high-risk deliveries appeared so widespread that the special effect of the RWJF program could not be detected.

Conclusion: Surveys of surviving 1-year-old infants showed that the decrease in neonatal mortality was accompanied by a decrease in selected morbidity.

Study Design: QE: pretest-posttest nonequivalent control group

Setting: Eight regions and eight comparison regions

Population of Focus: Infants born weighing ≤1500

Data Source: Data from reproduced computer tapes of births and matched infant death and birth certificates obtained from state and local health offices in several states.

Sample Size: Intervention group: Pretest (n≈ 4080) Intervention (n≈ 3416) Posttest: (n≈ 4033) Comparison: Pretest: (n≈ 5221) Intervention: (n≈ 4297) Posttest: (n≈ 4596)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems

Intervention Description: Analysis of a maternal transport service within a perinatal region.

Intervention Results: Analysis of perinatal statistics from the Loyola University Perinatal Center from 1979 to 1986 supports: (1) increasing numbers of maternal and neonatal transports, with the number of maternal transports exceeding the number of neonatal transports since 1982; (2) increasing proportion of low birthweight and very low birthweight infants delivered at the perinatal center; (3) a decrease in the number of infants less than 1500 gm sent as neonatal transports; and (4) increasing proportion of neonatal transports with a birthweight greater than 2500 gm.

Conclusion: The perinatal mortality rate for the region has decreased from 1981 to 1986.

Study Design: Time trend analysis

Setting: Metropolitan Chicago: Cook County and Suburban Dupage County Two level I, 11 level II, and one level III hospitals

Population of Focus: Infants born weighing >500 gm. Data for entire region only given from 1981-1986.

Data Source: Data obtained from the Illinois Department of Public Health and Loyola University annual statistics reports.

Sample Size: 1981 (n= 18,365) 1982 (n= 19,460) 1983 (n= 19,162) 1984 (n= 19,379) 1985 (n= 20,132) 1986 (n= 19,751)

Age Range: Not specified