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ANGELS: Does it Work?

ANGELS: Does it Work?. Whit Hall MD. ANGELS. Education Guidelines Referral Arkansas, a rural state 3 areas with practicing neonatologists Other areas with pediatricians. ANGELS: Education. Monthly teleconference meetings Face to face interaction Two way street AHEC contribution.

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ANGELS: Does it Work?

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  1. ANGELS: Does it Work? Whit Hall MD

  2. ANGELS • Education • Guidelines • Referral • Arkansas, a rural state • 3 areas with practicing neonatologists • Other areas with pediatricians

  3. ANGELS: Education • Monthly teleconference meetings • Face to face interaction • Two way street • AHEC contribution

  4. ANGELS: Guidelines • Buy-in to guidelines • Apnea • Pain • Hyperbilirubinemia, etc • Published in AMJ • Contribution of practicing physicians (e.g., recommendation on apnea) • Evidenced based

  5. ANGELS: Regionalization • Better communication • “Town gown” gap narrowed • More appropriate (not necessarily more) referrals • Is it a good thing for the preterm neonate??

  6. Regionalization: History • Improved outcomes in Wisconsin (Graven, 1977) • Improved outcomes in Canada (Sankaran K, 2002) • Improved rates of IVH Canada (Synnes a, 2002) • Improved outcomes in AR (Kirby, 1995, Palmer, Hall RW, 2005)

  7. Maternal referral • Numerous articles attesting to that • Improved outcomes in IVH in California (Towers C, 2000) and Kansas (Hall Robert, 2003) • Improved mortality outcomes in perinatal Canadian centers compared to free standing children’s hospitals (Shah P, 2005) • Decreased disability (Victorian Study Group, 1991) • Decreased mortality (Kollee, 1999; Warner, 2004; Lubchenco, 1989; Yeast, 1998; Cooper, 1999Obladen, 1994; Johansson, 2004; Gerlinde, 2005)

  8. But…. • Higher mortality at night in inborn units • Better (40%!) if in-house fellow or attending (Lee, SK, 2003) • Observed mortality less in hospitals without residency programs and less volume (104 vs. 62) (Horbar JD, 1997) • Outborn status protective in US Centers (NEOPAIN trial, Rao R, Hall RW, 2006) • No difference in mortality after adjusting for prenatal steroids (NEOPAIN trial, Palmer KG, Hall RW, 2005) • NEOPAIN trial required transfer within 7 hours

  9. Problems with Maternal Transport in Arkansas • Rural state with long distances to travel in preterm labor • Home for threatened preterm labor not well developed • Evolving transport system with established neonatal transport system • Hospital competition • Money, pride, prestige

  10. Summation of literature • Overwhelming support for regionalization • Overwhelming support for maternal transport • IVH always decreased in inborn population • Selection bias a problem in all studies • Refer patients who are “survivable” • Outborn babies may require emergency delivery • Abruption, Uterine rupture, prolapsed cord, etc

  11. ANGELS: Referral • Regionalization works • A neonatologist does not an intensive care nursery make • Hindrances to regionalization • Money • Prestige • Why UAMS??? Palmer, Hall, et al, 2005; Fanaroff & Martin, 7th ed, 2002

  12. Why We Started: Mortality Data from 1995-2000 ACH p=0.039 for 500-600gms VtOx p<0.001 for 500-600gms NICHD p<0.001 for 500-600gms ACH p=0.087 for 600-700 gms VtOx p=0.02 for 600-700gms NICHD p<0.005 for 600-700gms

  13. Why We Started: Mortality Data From 1995-2000 ACH p=0.0135 for 500-750 VtOx p<0.0001 for 500-750 NICHD p<0.0001 for 500-750 Vt Ox p=0.0065 for 750-1000 NICHD p=0.026 for 750-1000

  14. Why We Started: IVH Data From 1995-2000 500-750 750-1000 1000-1250 1250-1500 ACH p=0.047 p=0.33 p=0.002 p=0.02 NICHD p<.0001 p=.0004 p=.0261 p=.10

  15. Evidence • Better outcomes with inborn delivery in AR • Need for education • Medicaid deliveries • Large impact (55% coverage) • Easy to work with • Centralized

  16. Survival: 2001-2004 ** * *p<0.05 ** p<0.01

  17. Survival: 2001-2004 *p<0.05; **p<0.01 ** ** * *

  18. Survival: 2001-2004 **p<0.01 ** ** ** ** **

  19. Survival: 2001-2004 p<0.01 UAMS vs. all others

  20. Survival: 2001-2004 P<0.01 at all weights

  21. Grade 3 and 4 IVH Rate *p<0.05 **p<0.01 * ** ** **

  22. Why the Improved Outcomes at UAMS • Maternal Transport • Strong OB/Perinatal program • ACH backup • Nursing experience • UAMS administration backup • In house neonatal coverage • Medicaid

  23. Number of UAMS VLBW Admissions ANGELS

  24. What We Know • UAMS has better survival in VLBW neonates • Less IVH in the inborn population • ANGELS has increased inborn delivery • Back-up of ACH • Medicaid is in a good position to advocate for better outcomes regardless of pride and prestige

  25. What We Must Research • Cost • Initial hospital • Long term • Long term outcome and satisfaction of families • Quality of survival

  26. Conclusion • ANGELS is building a better medical system • IVH rates are markedly improved; survival is modestly affected in the system • More research is needed on long term outcomes and costs • ANGELS/Medicaid is a smart, cost effective system who cares for her clients, especially compared to other programs (FEMA) • Funding should remain intact for AHRQ, Medicaid, and ANGELS

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