TIOP I ( 1976)

1. Plenary Session II: The Role of State Health Departments in Examining Care for Adverse Pregnancy Outcomes Part one: Perspectives on the history of regionalization and the role of neonatology and states in improving outcomes. George A. Little December 7, 2005

2. Graven, S.N., Howe, G., and Callon, H., Perinatal health care in Wisconsin: 1967-70, In Neonatal Intensive Care. Swyer, P. A., and Stetson, J.A. Eds., Charles Green Publishers, 1976 (Presented to AAP, May 1971)

4. TIOP I ( 1976) • Emphasized needs assessment and resource allocation • Recommended universal risk assessment and organization of hospital based services ( levels of care) • Major tasks ahead identified • financing • professional education • initiating action

5. 1983

7. TIOP II 1993 • Broaden focus - preconception to follow-up ; greater emphasis on outpatient care • data, evaluation and accountability • Existing system of care with risk assessment and levels of care reconfirmed

8. Better care or better babies? • 50% decrease of <1500 g mortality in 2 cohort study ( 1989-90 and 1994-5) • 1/3 decline attributed to improved condition on admission • 2/3 decline attributed to NICU care Richardson et al, Pediatrics, 102, 1998

9. Are we doing the right thing? Silverman, W. Is neonatal medicine in the United States out of step? Pediatrics. 1993; 92: 612-613

10. Neonatal Care • has been responsible for much of the improvement in perinatal outcomes • will be able to contribute proportionately less to future outcome improvement • do we have an adequate capacity?

11. Pediatrics, 2001

13. Neonatal Care Capacity and Need • cross sectional analysis of 246 neonatal intensive care regions (NICRs) • association between capacity (neonatologists and beds) and LBW and VLBW

14. Neonatal Care Capacity and Need • Regional variation not explained by need as expressed by LBW • Variation across 246 NICRs greater than fourfold • High quintile 863 births/neon, 169 births/bed • Low quintile 3718 births/neon, 368 births/bed

15. 2002

16. Neonatal Care Capacity and Outcomes • study of relationship between 3,892,208 births >500 g and mortality • risk adjusted for maternal and neonatal factors

17. Neonatal Care Capacity and Outcomes • rate lower in second NICR quintile with 4.3 neonatologists than first with 2.7. No further improvement with added capacity in quintiles 3-5. • no consistent relationship between number of NICU beds and mortality

18. Is More Neonatal Intensive Care Always Better? Insights From a Cross-National Comparison of Reproductive Care Thompson LA, Goodman DC and Little GA, Pediatrics, 109, 2002

19. The US compared to 3 other developed countries : • does not have consistently better birth-weight specific mortality • has LBW rates that exceed other countries • has less extensive preconception and prenatal services • Expends significantly greater NICU resources/capita

20. Inefficient Harmful Patient Benefit Health Care Supply Theoretical Relationship of Capacity to Outcomes Adequate Underserved

21. Pediatrics, 103,1 Jan 1999

22. State perinatal QI, mandated arenas of activity • policy development and implementation • definition and measurement of quality • data collection and analysis • communication to affect change

23. Survey of state MCH agencies (1998) • few state agencies undertaking efforts in all four areas • there is opportunity for states to be more proactive as they have legal authority and responsibility to assure MCH outcomes.

25. Ohio • 1977 State Perinatal Guidelines 6 geographically defined Regional Perinatal Centers Regional Perinatal Education Coordinators

26. Ohio • 2002 Perinatal Data Use Consortium (DUC) created • Engage both medicine and public health • PPOR utilized • 6 regional teams for data-driven projects • Create state-wide consortium • Gradually evolve to use data for decision making and quality improvement

27. Vermont Oxford Network VLBW Infants NICUs 1991 to 2004 1991 to 2004 Database now includes ¼ million records 13% of members are international

28. Paper Forms Infants <1500 gm Printed Reports Digital Forms All NICU Infants Internet Reporting Database Evolution 2000 2005 • Electronic submissions increasing • eNICQ Software in field • Expanded Database increasing • CD-ROM reporting in place • Secure Internet reporting in 2005

30. CALIORNIA PERINATAL QUALITY CARE COLLABORATIVE(CPQCC)

32. Grady Hospital’s Interpregnancy Care Program: A Model Intervention in Response to the Conversion of Data into Information A.W. Brann, Jr., MD, Director Brian McCarthy, MD, PI Georgia Perinatal Task Force Anne Lang Dunlop, MD, MPH Research Fellow, WHO Collaborating Center

33. Objectives • To review the Perinatal Periods of Risk (PPOR) model for identifying opportunity gaps and corresponding health system interventions to improve feto-infant mortality for a given location; • To demonstrate use of the PPOR model to identify excess feto-infant mortality and interventions for reducing feto-infant mortality for Georgia; 3. To present an overview of Grady Hospital’s Interpregnancy Care Program, a health system intervention for potentially decreasing recurrent adverse pregnancy outcomes for high-risk women.