Established Evidence Results

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, STATE, Policy/Guideline (State), Funding Support, Perinatal Committees/Councils

Intervention Description: Vital records data (1971 to 1978) were used to assess the change in neonatal and fetal mortality in Colorado in relationship to the regionalization of perinatal health care within the state.

Intervention Results: There has been a decrease in neonatal mortality rate from 13.4 to 6.9 during a period of time when there was a minimal decrease in the incidence of low-birth weight infants. The improved neonatal mortality has been associated with a shift in the frequency of birth of very low-birth weight (VLBW) infants to hospitals with level II and III perinatal services and relatively greater survival rates of VLBW infants born in these hospitals as compared to those born in level I hospitals. There was no decrease in fetal mortality in the same period of time.

Conclusion: These date suggest that outreach education in perinatal medicine should now emphasize current knowledge and methods for reducing antepartum deaths.

Study Design: QE: pretest-posttest

Setting: All Colorado hospitals Three level III, seven level II, remaining level I

Population of Focus: Infants born weighing greater than one lb.

Data Source: Data from the Bureau of Vital Records, Colorado State Health Department.

Sample Size: Pretest: 1.8% (n=2,818) Posttest: 1.8% (n=2,967) Infants born weighing one to four lbs.

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): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), STATE, Perinatal Committees/Councils

Intervention Description: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. Under the ACA, states retain significant flexibility in terms of eligibility and program structure. Approaches to state-level expansions to parents include providing public health insurance with or without an enrollee premium and providing subsidies for private health insurance. The Oregon Experiment (Medicaid expansion) gave a subset of uninsured, low-income adults access to Medicaid through a randomized selection process.

Intervention Results: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid; findings demonstrate a causal link between parents’ access to Medicaid coverage and their children’s coverage. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected. In the immediate period after selection, children whose parents were selected to apply for Medicaid significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a non-significant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. The effect remained significant during months 7 to 12; months 13 to 18 showed a positive but not significant effect. Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage.

Conclusion: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents’ access to Medicaid coverage and their children’s coverage.

Study Design: Randomized natural experiment; generalized estimating equation models

Setting: Policy (Oregon Medicaid expansion program)

Population of Focus: Children whose parents participated in the Oregon Experiment (Medicaid expansion program)

Data Source: The Oregon Experiment’s reservation list data; Oregon Health Plan (OHP) administrative data

Sample Size: 14,409 children

Age Range: 2-18 Years

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): 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