Abstract and Introduction
Abstract
Objective: We assessed a telemedicine (TM) network's effects on decreasing deliveries of very low birth weight (VLBW, <1500g) neonates in hospitals without Neonatal Intensive Care Units (NICUs) and statewide infant mortality.
Study design: This prospective study used obstetrical and neonatal interventions through TM consults, education and census rounds with 9 hospitals from 1 July 2009 to 31 March 2010. Using a generalized linear model, Medicaid data compared VLBW birth sites, mortality and morbidity before and after TM use. Arkansas Health Department data and χ analysis were used to compare infant mortality.
Result: Deliveries of VLBW neonates in targeted hospitals decreased from 13.1 to 7.0% (P=0.0099); deliveries of VLBW neonates in remaining hospitals were unchanged. Mortality decreased in targeted hospitals (13.0% before TM and 6.7% after TM). Statewide infant mortality decreased from 8.5 to 7.0 per 1000 deliveries (P=0.043).
Conclusion: TM decreased deliveries of VLBW neonates in hospitals without NICUs and was associated with decreased statewide infant mortality.
Introduction
Very low birth weight (VLBW, birth weight <1500 g) neonates are among the most critically ill and fragile patients within the modern health-care system. Mortality rates range from 15 to 25% and survival with major morbidity remains high. VLBW neonates born in large perinatal centers have improved survival and adverse outcomes when compared with similar neonates born in hospitals without subspecialty care; thus, regionalization has the potential to reduce mortality and morbidity in the VLBW neonate population. Unfortunately, despite the well-known benefits of regionalization, de-regionalization of Neonatal Intensive Care Unit (NICU) care has continued to occur.
Perinatal regionalization connotes a system of health care for mothers and neonates organized within a geographic area. This concept assesses risk, promotes resource allocation and appropriate patient transport, and differentiates levels of care to deliver the best quality of care in the most economical manner. Guidelines for perinatal care, endorsed by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology, have defined levels of care and minimum requirements for caring for high-risk pregnancies likely to result in premature neonates. These guidelines recommend that neonates <32 weeks gestation or <1500 g be delivered in Level III perinatal centers, which provide neonatal and subspecialty care. However, as the number of hospitals caring for these mothers and their infants has increased, the movement toward regionalized perinatal care has declined. Further, there is substantial variation in effective regionalized perinatal care among states. The Federal Maternal and Child Health Bureau established a goal aimed at delivering 90% of VLBW neonates in Level III perinatal centers. In 2009, according to the US Maternal and Child Health Bureau, only seven states achieved that goal. Thus, interventions to improve regionalized care and lower mortality are desperately needed. Telemedicine (TM) offers a novel solution for bringing patients with the greatest needs together with tertiary care resources. TM has been used in NICUs to assess for retinopathy of prematurity in VLBW neonates in obstetrical units to provide fetal ultrasonography, in cardiology to perform echocardiography, and to provide education and family support.
In 2003, Arkansas established a statewide system for high-risk obstetrics and neonatology, Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS). ANGELS provided an infrastructure for TM collaboration, consultation and development and adoption of best practices. However, TM effectiveness in improving regionalization in high-risk neonatal populations has not been fully demonstrated. This study was undertaken to determine whether TM could decrease VLBW deliveries in hospitals without NICUs, impact morbidity and mortality in this patient population and decrease statewide infant mortality.