Showing posts with label perinatal care. Show all posts
Showing posts with label perinatal care. Show all posts

Tuesday, July 28, 2015

Home Is Where The Heart Is: New Ways of Thinking About Discharge Planning


By: Lydia Furman, MD,  Assistant Editor 
 
      Discharging preterm infants is an arduous duty.  Both residents and supervising neonatologists are familiar with the many pitfalls that hold up the show. Coordination of care, services and appointments, and needed equipment, are massive tasks. And there is often enough angst about readiness- i.e. “will this baby ‘fly’ and “will the parents be able to meet the baby’s needs” – to put off the discharge date several days for non-medical reasons.  All that is in addition to the strong desire of parents to finally “escape” home with their baby.  Any prolongation of the hospital stay is very expensive.
Dr. Temple et al. (doi: 10.1542/peds.2015-0456) have written a highly pragmatic article that gives providers a new “crystal ball” algorithm with which to plan discharges.  Using daily progress note information, their work teaches us how to predict discharge within a 2-10 day period, giving providers and staff the information and a level of certitude with which to plan.  They emphasize that their study is not about predicting length of stay at admission, but it’s about using “real time” data to predict future discharge during the hospital stay.
      What parameters are most useful? It’s an interesting exercise to try to predict or guess ahead what information will be most useful. Will it be lab values, growth parameters, feeding information, cessation of “A’s and B’s” (apneas and bradycardias), vital signs, original birthweight or gestational age, number of medications, or some golden combination of these?
      The authors evaluated a total of 4,693 patients and 103,206 patient-days, and examined four subpopulations, including premature infants, babies with cardiac disease, babies with gastrointestinal surgery, and those with neurosurgical conditions. They used progress notes to identify qualitative and quantitative parameters, and two types of “derived” or calculated data. The retrospective data they used is clinical and intuitive, and highly available, and will likely appeal to neonatologists and trainees. Ultimately with the use of just two features (no spoiler here- please read to find out!), days to discharge of 4 days can be predicted with surprising accuracy for three of the four subpopulations (neurosurgical patients were a challenge for the algorithm). This excellent work needs prospective confirmation, but the results are highly encouraging.
       Clearly the most important thing is getting babies and parents home in a way that is comfortable and safe, but there is a huge carrot at the end for making this transition as timely as possible. A brief peek at some crude financial data suggests that the work of Temple and colleagues has the potential to create enormous societal savings. The average cost of a preterm birth in the US is $32,325, and for infants born at less than 28 weeks, the average cost of the hospital stay was $280,811 (March of Dimes Peristats, https://www.marchofdimes.org/peristats). Single day charges for the NICU range around $3,000, not including costs related to specific surgical procedures or imaging (http://www.managedcaremag.com/archives/1001/1001.preterm.html).   
      Thus any comprehensive incremental decreases in length of NICU hospital stay could have a profound impact on total health care dollars.  Kudos to the authors for their forward thinking work, since ultimately safe healthcare change must be driven and led by knowledgeable physicians, rather than by administrators or insurance companies alone.

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Friday, April 24, 2015

Does Extremely Preterm Outcome Hinge on the Intensity of Perinatal Care Provided?




      We often read that investing resources into the tiniest of preterm babies may not be cost-effective given the mortality risk as well as the neurodevelopmental disability that can occur in the extremely preterm infant. Yet maybe the more intensive care resources we provide, the better the outcomes?  That opinion is substantiated by Serenius et al. (doi:10.1542/peds.2014-2988) as they describe some interesting findings using a national prospective study of more than 800 fetuses alive at the time a mother was admitted for delivery.  To our surprise, being proactive and increasing the intensity of perinatal care does result in some pretty impressive risk-reduction in these ELBW infants. So what should we conclude about the use of proactive care in this high risk population of infants.   
      Doctor Cody Arnold and Doctor Eric Eichenwald weigh in with an accompanying commentary that sheds further light on the findings in this study (doi: 10.1542/peds.2015-0536) Maybe the cost is outweighed by the benefit—but we’d love to know your thoughts about how much is too much when it comes to trying to provide whatever it takes to help an extremely preterm baby? 
     Share your opinion on the findings in this study by responding to our blog, writing an e-letter or post your comments on our Facebook or Twitter sites.

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Wednesday, April 22, 2015

Perinatal Transmission of Hepatitis B: What Factors Increase Risk of Transmission Despite Immunoprophylaxis?



      We have made such great strides  immunoprophylactically treating infants born to mothers who are hepatitis B surface antigen  (HBsAg)positive to the point where 95% of perinatal hepatitis B viral (HBV) infections are prevented—but some still occur.   Thus the question is which infants are most likely to be at risk of getting HBV infection despite immunoprophylaxis?  This week Schillie et al. (doi:10.1542/peds.2014-3213) answer that question using some prospectively collected data from several Hepatitis B prevention programs from 2007 to 2013 to identify risk factors for perinatal transmission.  The authors looked at maternal demographics, lab results, infant birth weight and gestational age, and the immunotherapy used from an analysis of almost 18,000 mother-infant pairs.  
      In this study only 1.1% of babies acquired HBV infection from their mothers despite the vast majority of these babies having gotten immunoprophylaxis.  Just what factors increase a baby’s risk of infection?  Some include younger maternal age, maternal viral load, and maternal hep e antigen positivity—but there are even more to be concerned about. Helping to make sense of the findings of this study and to share some thoughts on how to do even more to reduce the perinatal transmission of this virus is an accompanying commentary by Dr. Ravi Jhaveri (doi:10.1542/peds.2015-0360).   
       Hopefully you’re now so hepped up from this description of the study—you’ll link to the article and commentary and learn which of your patients are at highest.

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Wednesday, October 29, 2014

Association Between Perinatal Complications and Accelerated Aging at Midlife

By: Lewis First, MD, MS; Editor-in-Chief 

Public domain photo via Pixabay
We certainly have published myriads of studies noting the role of perinatal complications increasing risks for morbidity and mortality in early childhood—but what about later in life?

Can a perinatal stressful event lead to earlier aging processes in adulthood?

It’s a fascinating hypothesis that Shalev et al. (doi:10.1542/peds.2014-1669) set out to study looking at leucocyte telomere length and perceived facial age of a prospective cohort of more than 1,000 adults who have been studied since birth for 38 years. In this study, even when controlling for potential confounders, authors found an association between perinatal maternal and infant complications and subsequent aging indicators.

Just why or how this might occur is discussed by the authors and also in a thought-provoking commentary by Dr. Alan Guttmacher, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and Dr. Tonse Raju (medical program officer for the NICHD) (doi:10.1542/peds.2014-2646) that also warrants your consideration.

The idea that perinatal programming can influence how we age is a fascinating concept—but it’s even more fascinating when this study begins to show this to be true. Clearly we will need even more research in the months and years ahead to better identify the mechanisms at play that promote accelerated aging as a result of perinatal complications.