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The impact of managed clinical networks on place of birth and newborn transfers

The impact of managed clinical networks on place of birth and newborn transfers. Chris Gale On behalf of the Neonatal Data Analysis Unit and the Medicines for Neonates Investigator Group. Background. Neonatal services reorganised in 2003 into managed clinical networks

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The impact of managed clinical networks on place of birth and newborn transfers

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  1. The impact of managed clinical networks on place of birth and newborn transfers Chris Gale On behalf of the Neonatal Data Analysis Unit and the Medicines for Neonates Investigator Group

  2. Background • Neonatal services reorganised in 2003 into managed clinical networks • Increase provision of high quality neonatal care • No formal mechanism established to evaluate the impact of reorganisation on patient care • Among preterm infants: • Delivery and initial care at specialised units is associated with improved outcomes (Lasswell 2010) • Acute postnatal transfer is associated with adverse outcomes (Mohamed 2010, Towers 2000) Reflected in key aims of 2003 reorganisation Amenable to evaluation

  3. Aims • Use data, routinely collected by units, to evaluate the effectiveness of reorganisation in managed clinical networks • Before and after analysis of the following outcomes: • Proportion of preterm babies delivered in neonatal units with the greatest neonatal intensive care experience • Proportion of preterm babies undergoing early transfer: before 24 hours of age • Proportion of preterm babies undergoing late transfer: between 24 hours and 28 days • Proportion of multiple birth sets separated by postnatal transfer

  4. Study design 1998 2002 2004 2000 2006 2008 2010 Epoch 1 Epoch 2 • Epoch 1: Before reorganisation • Extracted from CESDI Project 27/28 • 1st September 1998 to 31st August 2000 • Babies born alive at 27/28 gestational weeks • Epoch 2: After reorganisation • Your data! • 1st January 2009 to 31st December 2010 • Babies admitted to a neonatal unit at 27/28 gestational weeks Reorganisation

  5. Data analyses • Differences between epochs: Level of neonatal unit at hospital of birth and transfer status • χ2 test • Dichotomous outcomes: Level of neonatal unit at hospital of birth (≥2000 vs <2000) and multiple birth sets separated by transfer • Risk difference (RD) [95% Confidence Intervals] • Odds ratio (OR) [95%CI]

  6. Results • Epoch 1: Before reorganisation • 294 centres providing maternity care • No standard definition of neonatal unit level • 148 providing >48 hours of ventilation • 3522 babies between 27 weeks+0 days to 28 weeks+6 days • Epoch 2: After reorganisation • Data from 146 of 173 neonatal units in 23 neonatal networks • 34 level one, 72 level two, 40 level three units • 2919 babies between 27 weeks+0 days to 28 weeks+6 days • No clinically important differences in demographic characteristics between epochs

  7. Results: Place of birth Proportion delivered in at hospitals with the highest activity NICU increased significantly: • RD of 31% [28%, 23%], OR 4.3 [3.83, 4.82]

  8. Categorisation of neonatal units in epoch 2

  9. Results: Transfers • Significantly greater proportion of babies undergoing both acute and later postnatal transfer between epochs

  10. Transfers in epoch 2 125 To higher level unit To lower level unit To equivalent unit 100 Number of transfers 75 50 25 0 Postnatal age (days)

  11. Results: Multiple births separated • No significant difference detected between epochs • RD 3% [-15%, 8%] • OR 0.86 [0.50, 1.46]

  12. Limitations and strengths • Limitations • Association between reorganisation and outcomes • Aggregated data only for epoch one • Unable to analyse underlying trends in outcomes • Strengths • Large numbers • National distribution of units in both epochs • Unambiguous, clearly defined outcomes • Epoch two represents current state of neonatal care in England

  13. Summary Following reorganisation • Increase in proportion of babies delivered at high volume units • In keeping with a key aim of reorganisation • Over half of babies still delivered at lower volume neonatal units • Room for improvement • Increase in acute transfers • Key aim of reorganisation not being met • 1 in 8 babies undergo transfer within first day: 30% to an equivalent or lower level unit • Multiple birth sets continue to be separated by transfer • Cot capacity impacting on clinical care • Better understanding of the clinical implications transfers

  14. Acknowledgements • Clinicians and other health professionals contributing high quality data • Neonatal Data Analysis Unit • Shalini Santhakumaran Eugene Statnikov • Sridevi Nagarajan • Imperial College London Academic Neonatal Medicine • NDAU Steering Board • Jane Abbott Jacquie Kemp • Peter BrocklehurstAzeemMajeed • Kate Costeloe Neena Modi • Liz Draper Alys Young • Deborah Ashby Andrew Wilkinson • Stavros Petrou

  15. Survival • Significantly higher survival in England in epoch 2 vs epoch 1 • RD 5.6% [4.2%, 7.0%], OR 2.00 [1.67, 2.40], p<0.001

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