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Quality improvement using neonatal network data

Mark Adams, PhD Swiss Neonatal Network & Follow-up Group. Quality improvement using neonatal network data. SNQ Congress, Stockholm March 28, 2019. O verv i ew. • • • • •. Short introduction into Swiss Neonatal Network

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Quality improvement using neonatal network data

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  1. Mark Adams,PhD Swiss Neonatal Network & Follow-upGroup Quality improvement using neonatal networkdata SNQ Congress,Stockholm March 28,2019

  2. Overview • • • • • Short introduction into Swiss NeonatalNetwork How do we understand quality improvement How to achieve qualityimprovement Where do we stand in Switzerland Discussion

  3. SwissNeoNet An association of all 9Swiss Level III neonatology units with 10 Level IIB(step-down) unitsand 16 Neuro-/Developmental pediatricunits (longtermfollow-up)

  4. Switzerland: ca. 8.5 mio inhabitants ca. 80,000 births peryear ca. 1% (850) very preterm, steadily rising SwissNeoNet covers ca. 96% of allbirths

  5. onet.ch Data collected for high-risknewborns Minimal NeonatalDataset <32w GA, <1500gBW B34Dataset 32 0/7 – 33 6/7wGA AsphyxiaDataset HIE OrchidDataset Heartsurgery Follow-upat 2 yearscorrected Follow-upat 5-6years

  6. Introduction Mainactivities: Research: observational / cohort / ecologicalstudies Quality assessment /improvement Follow-up coordination / quality (workshops, seminars,logistics) RCTsupport

  7. Switzerland: • Diversity: • 4 languages • 26 cantons with independent health careauthorities • A third of residents have migrationbackground

  8. SwissNeoNetcollaboration Neo DirectorsGroup: 2 meetings per year: fully transparent outcomecomparisons Follow-upGroup: 2 meetings per year: teachings /coordination Networkregulations: Everyone can apply to use data – no response =agreement

  9. Definition Qualityimprovement Giving a lecture inSweden? = Selling ice to anEskimo

  10. Definition Qualityimprovement Giving a lecture inSweden? = Selling to anEskimo

  11. Definition Qualityimprovement = exploiting unwarranted variationbetween health careproviders

  12. Definition Unwarrantedvariation = variation in health care that cannot be explained by patient illness orpreferences

  13. Why did our doctor not ask usif we agreed to redirection ofcare Hey, our baby had noantenatal steroids –why? our baby’s surgeon insistedon surgery forPDA. He’s theexpert!

  14. Types of unwarrantedvariation • Effectivecare: • variation in services that have a solid evidencebase. • Preference-sensitivecare: • variation in treatments where legitimate treatment optionsexist. • Supply-sensitivecare: • variation in services where the supply has major influence onutilization • (Wennberg J, Health Aff 2003, BMJ2011)

  15. Effectivecare • Ideal: • Each medical practice performed has a solid evidencebase • This solid evidence base can be adjusted to eachpatient • The evidence is known and available toall

  16. Effectivecare • Reality: E.g. Antenatalsteroids • Evidence base is as solid as itgets: • >30RCTs • Several systematic reviews,meta-analyses • Cochrane databaseentries • Recent lecture by Alan Jobe (VON2017): • RCTs performed < 2000: change in neonatalpopulation • No clear benefit shown for infants born < 28weeks

  17. Effectivecare Reality:

  18. Effectivecare • Why is there unwarrantedvariation: • Many practices have no clear evidencebase • Patient may not fit into typical (RCT)picture • Hospital cannot affordinfrastructure • Ignorance? • Humanerror? • Underuse of effectivecare

  19. Effictivecare What can bedone? Good Potentialto improve Hospital1 Hospital2

  20. Effectivecare • How do we approachimprovement: • Underuse of effectivepractice • SwissNeoNet produces annual qualityreport

  21. Effectivecare • How do we approachimprovement: • Underuse of effectivecare • SwissNeoNet produces annual qualityreport • Biannualmeetings: • Most prominent unwarranted variationsselected • Selected unwarranted variations standarddiscussion

  22. Effectivecare • How do we approachimprovement: • Underuse of effectivecare • SwissNeoNet produces annual qualityreport • Biannualmeetings: • Most prominent unwarranted variationsselected • Selected unwarranted variations standarddiscussion • Swiss Society of Neonatology develops / reviewsguidelines • Units perform local quality improvementprojects

  23. Effectivecare • How do we approachimprovement: • Underuse of effectivecare • Missing: coordinated quality improvement involving allstaff, • e.g. EPIQ • Missing: transparent publication of at least a selection of results of the qualityreport

  24. Patient sensitivecare • Ideal: • When two or more treatment options are available, the patient is sufficiently informed to be able to decide for the option fitting her /him.

  25. Patient sensitivecare • Reality: • Your friend / daughter is 23 weekspreagnant. • Birth is imminent. She lives inSwitzerland. • Retrospective study of Swiss preterm births between 22 – 26 weeks gestation 2012 – 2015 (Berger et al. BMJ open,2017): • Decision for providing intensive care based largely on infant having reached 24weeks

  26. 08.04.2P0ag1e929Slide29

  27. 08.04.2019 Slide30

  28. Association between perinatal interventional activity and 2-year outcome of Swiss extremely preterm born infants: a population-based cohortstudy Group1 Group2 08.04.2019 Slide31

  29. Association between perinatal interventional activity and 2-year outcome of Swiss extremely preterm born infants: a population-based cohortstudy 22- 25 weeksGA 26- 27 weeksGA 08.04.2019 Slide32

  30. Patient sensitivecare • Missing / in development: Parental involvement incare • New guidelines for infants born < 25 weeks: attempt at improved shared decisionmaking • Follow-up Group: survey on what outcomes parents are interestedin 08.04.2019 Slide33

  31. Supply sensitivecare • Ideal: • Medical care is available where needed and provided only if required. 08.04.2019 Slide34

  32. Supply sensitivecare • Reality: • Patent DuctusArteriosus • Treatment options: none, medical,surgical • Variation in Switzerland (infants < 28 weeks, 2014 –2017): • Medical: 17% -68% • Surgical: 0% -26% 08.04.2019 Slide35

  33. Supply sensitivecare Standards for Levels of Neonatal Care inSwitzerland 08.04.2019 Slide36

  34. Supply sensitivecare • Standards for Levels of Neonatal Care inSwitzerland • Staffing (Physicians 24/7 – Nurse to Bedratio) • Processes (Admissions / respiratorysupport) • Quality and Outcomemeasurement 08.04.2019 Slide37

  35. Unwarrantedvariations • IDEAL REALITY • Underuse of evidence basedpractices • Misinformation, lack of information, lack of time to inform patients • Overuse of ineffectivepractices • Maybe medling with the system to generate income. Unwillingness to reform • But also: willingness to self-reflect, grow, exploitpotential 08.04.2019 Slide38

  36. Why I ♥ unwarrantedvariation • it is natural: there will always bevariation • it is to beexpected: • - +10'000 new RCTs in medicine each year/ • - 17 years for implementation of newevidence • it is human: medical staff are allowed makemistakes • most of all: it provides a constant opportunity forimprovement. 08.04.2019 Slide39

  37. Why I ♥ unwarrantedvariation • Alan R. Spitzer (Clin. Per.2017): • "The reality of health care is that despite best efforts and best intentions, at times, high-quality care is notachieved.“ • “The emergence of outcome measurement and quality improvement in the neonatal intensive care unit, far more than the introduction of new research approaches or novel therapies, has had a profound effect on improving outcomes for prematureneonates.” 08.04.2019 Slide40

  38. Canadian neonatal quality improvement: EPIQ3 Shah et al., 2018, Can. J. Physiol.Pharmacol. 08.04.2019 Slide41

  39. How to approach unwarrantedvariation • Effective care: • Target underuse of effectivecare • Quality assessment: Patient level process and outcomecomparisons • Quality improvement: EPIQ,VON • Preference sensitivecare • Patient information / shared decisionmaking • Advance patientinvolvement • Supply sensitive care • Target overuse of ineffectivecare • E.g. Choosing wisely, Unit levelcomparisons • Minimum casenumbers 08.04.2019 Slide42

  40. Commondenominator • High qualitydata • to differentiate between health careproviders • to adjust for patient risk, needs orpreferences • Ability / willingness forintrospection • Perform the unpopular study: retrospective cohortstudy • Adopting strategies from industry: accept lack in scientificrigor 08.04.2019 Slide43

  41. SWISSNEONETCORE 08.04.2019 Slide44

  42. SwissNeoNetCollaborators Aarau: Cantonal Hospital Aarau, Children's Clinic, Department of Neonatology (Ph. Meyer, C. Anderegg), Department of Neuropaediatrics (A. Capone Mori, D. Kaeppeli); Basel: University of Basel Children’s Hospital (UKBB), Department of Neonatology (S. Schulzke), Department of Neuropaediatrics and Developmental Medicine (P. Weber); Bellinzona: San Giovanni Hospital, Department of Pediatrics (G.P. Ramelli, B. Simonetti Goeggel); Berne: University Hospital Berne, Department of Neonatology (M. Nelle), Department of Pediatrics (B. Wagner), Department of Neuropaediatrics (M. Steinlin, S. Grunt); Biel: Development and Pediatric Neurorehabilitation Center (R. Hassink); Chur: Children's Hospital Chur, Department of Neonatology (T. Riedel), Department of Neuropaediatrics (E. Keller, Ch. Killer); Fribourg: Cantonal Hospital Fribourg, Department of Neuropediatrics (K. Fuhrer); Lausanne: University Hospital (CHUV), Department of Neonatology (J.-F. Tolsa, M. Roth-Kleiner), Department of Child Development (M. Bickle-Graz); Geneva: Department of child and adolescent, University Hospital (HUG), Neonatology Units (R. E. Pfister), Division of Development and Growth (P. S. Huppi, C. Borradori-Tolsa); Lucerne: Children's Hospital of Lucerne, Neonatal and Paediatric Intensive Care Unit (M. Stocker), Department of Neuropaediatrics (T. Schmitt-Mechelke, F. Bauder); Lugano: Regional Hospital Lugano, Department of Pediatrics (V. Pezzoli); Muensterlingen: Cantonal Hospital Muensterlingen, Department of Pediatrics (B. Erkert, A. Mueller); Neuchatel: Cantonal Hospital Neuchatel, Department of Pediatrics (M. Ecoffey); St. Gallen: Cantonal Hospital St. Gallen, Department of Neonatology (A. Malzacher), Children's Hospital St. Gallen, Neonatal and Paediatric Intensive Care Unit (J. P. Micallef), Department of Child Development (A. Lang-Dullenkopf); Winterthur: Cantonal Hospital Winterthur, Department of Neonatology (L. Hegi), Social Pediatrics Center (M. von Rhein); Zurich: University Hospital Zurich (USZ), Department of Neonatology (D. Bassler, R. Arlettaz), University Children's Hospital Zurich, Department of Neonatology (V. Bernet) and Child Development Centre (B. Latal, G.Natalucci). 08.04.2019 Slide45

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