First name
Sara
Middle name
C
Last name
Handley

Title

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial.

Year of Publication

2023

Number of Pages

188-193

Date Published

03/2023

ISSN Number

1468-2052

Abstract

OBJECTIVE: To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.

DESIGN: Single-arm, non-randomised, feasibility trial.

SETTING: Three centres in the Children's Hospital of Philadelphia neonatal care network.

PATIENTS: Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO) >0.25 on CPAP of 4-7 cm HO.

INTERVENTIONS: We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.

MAIN OUTCOME MEASURES: Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.

RESULTS: There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm HO.

CONCLUSIONS: Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.

TRIAL REGISTRATION NUMBER: NCT02983825.

DOI

10.1136/archdischild-2022-324474

Alternate Title

Arch Dis Child Fetal Neonatal Ed

PMID

36104165
Featured Publication
No

Title

Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants.

Year of Publication

2023

Number of Pages

278-285

Date Published

03/2023

ISSN Number

2168-6211

Abstract

IMPORTANCE: A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown.

OBJECTIVE: To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database.

EXPOSURES: NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs).

MAIN OUTCOMES AND MEASURES: The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type.

RESULTS: Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score.

CONCLUSIONS AND RELEVANCE: In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.

DOI

10.1001/jamapediatrics.2022.5213

Alternate Title

JAMA Pediatr

PMID

36648939
Featured Publication
No

Title

Association Between Neonatal Intensive Care Unit Type and Quality of Care in Moderate and Late Preterm Infants.

Year of Publication

2023

Date Published

01/2023

ISSN Number

2168-6211

Abstract

IMPORTANCE: A higher level of care improves outcomes in extremely and very preterm infants, yet the impact of neonatal intensive care unit (NICU) level on moderate and late preterm (MLP) care quality is unknown.

OBJECTIVE: To examine the association between NICU type and care quality in MLP (30-36 weeks' gestation) and extremely and very preterm (25-29 weeks' gestation) infants.

DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a prospective analysis of 433 814 premature infants born in 465 US hospitals between January 1, 2016, and December 31, 2020, without anomalies and who survived more than 12 hours and were transferred no more than once. Data were from the Vermont Oxford Network all NICU admissions database.

EXPOSURES: NICU types were defined as units with ventilation restrictions without surgery (type A with restrictions, similar to American Academy of Pediatrics [AAP] level 2 NICUs), without surgery (type A) and with surgery not requiring cardiac bypass (type B, similar to AAP level 3 NICUs), and with all surgery (type C, similar to AAP level 4 NICUs).

MAIN OUTCOMES AND MEASURES: The primary outcome was gestational age (GA)-specific composite quality measures using Baby-Measure of Neonatal Intensive Care Outcomes Research (Baby-MONITOR) for extremely and very preterm infants and an adapted MLP quality measure for MLP infants. Secondary outcomes were individual component measures of each scale. Composite scores were standardized observed minus expected scores, adjusted for patient characteristics, averaged, and expressed with a mean of 0 and SD of 1. Between May 2021 and October 2022, Kruskal-Wallis tests were used to compare scores by NICU type.

RESULTS: Among the 376 219 MLP (204 181 [54.3%] male, 172 038 [45.7%] female; mean [SD] GA, 34.2 [1.7] weeks) and 57 595 extremely and very preterm (30 173 [52.4%] male, 27 422 [47.6%] female; mean [SD] GA, 27.7 [1.4] weeks) infants included, 6.6% received care in type A NICUs with restrictions, 29.3% in type A NICUs without restrictions, 39.7% in type B NICUs, and 24.4% in type C NICUs. The MLP infants had lower MLP-QM scores in type C NICUs (median [IQR]: type A with restrictions, 0.4 [-0.1 to 0.8]; type A, 0.4 [-0.4 to 0.9]; type B, 0.1 [-0.7 to 0.7]; type C, -0.7 [-1.6 to 0.4]; P < .001). No significant differences were found in extremely and very preterm Baby-MONITOR scores by NICU type. In type C NICUs, MLP infants had lower scores in no extreme length of stay and change-in-weight z score.

CONCLUSIONS AND RELEVANCE: In this cohort study, composite quality scores were lower for MLP infants in type C NICUs, whereas extremely and very preterm composite quality scores were similar across NICU types. Policies facilitating care for MLP infants at NICUs with less complex subspecialty services may improve care quality delivered to this prevalent, at-risk population.

DOI

10.1001/jamapediatrics.2022.5213

Alternate Title

JAMA Pediatr

PMID

36648939

Title

Variation and Temporal Trends in Delivery Room Management of Moderate and Late Preterm Infants.

Year of Publication

2022

Date Published

07/2022

ISSN Number

1098-4275

Abstract

BACKGROUND: Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants.

METHODS: Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks') without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time.

RESULTS: Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment.

CONCLUSIONS: The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.

DOI

10.1542/peds.2021-055994

Alternate Title

Pediatrics

PMID

35851607

Title

Perinatal outcomes for rural obstetric patients and neonates in rural-located and metropolitan-located hospitals.

Year of Publication

2022

Author

Date Published

08/2022

ISSN Number

1476-5543

Abstract

OBJECTIVE: To compare rural obstetric patient and neonate characteristics and outcomes by birth location.

METHODS: Retrospective observational cohort study of rural residents' hospital births from California, Pennsylvania, and South Carolina. Hospitals in rural counties were rural-located, those in metropolitan counties with ≥10% of obstetric patients from rural communities were rural-serving, metropolitan-located, others were non-rural-serving, metropolitan-located. Any adverse obstetric patient or neonatal outcomes were assessed with logistic regression accounting for patient characteristics, state, year, and hospital.

RESULTS: Of 466,896 rural patient births, 64.3% occurred in rural-located, 22.5% in rural-serving, metropolitan-located, and 13.1% in non-rural-serving, metropolitan-located hospitals. The odds of any adverse outcome increased in rural-serving (aOR 1.27, 95% CI 1.10-1.46) and non-rural-serving (aOR 1.35, 95% CI 1.18-1.55) metropolitan-located hospitals.

CONCLUSION: One-third of rural obstetric patients received care in metropolitan-located hospitals. These patients have higher comorbidity rates and higher odds of adverse outcomes likely reflecting referral for higher baseline illness severity.

DOI

10.1038/s41372-022-01490-7

Alternate Title

J Perinatol

PMID

35963889

Title

Changes in preterm birth during the COVID-19 pandemic by duration of exposure and race and ethnicity.

Year of Publication

2022

Date Published

08/2022

ISSN Number

1476-5543

Abstract

OBJECTIVE: We aimed to determine whether coronavirus-disease-2019 (COVID-19) pandemic exposure duration was associated with PTB and if the pandemic modified racial disparities.

STUDY DESIGN: We analyzed Philadelphia births and replicated in New Haven. Compared to matched months in two prior years, we analyzed overall PTB, specific PTB phenotypes, and stillbirth.

RESULTS: Overall, PTB was similar between periods with the following exceptions. Compared to pre-pandemic, early pregnancy (<14 weeks') pandemic exposure was associated with lower risk of PTB < 28 weeks' (aRR 0.60 [0.30-1.10]) and later exposure with higher risk (aRR 1.77 [0.78-3.97]) (interaction p = 0.04). PTB < 32 weeks' among White patients decreased during the pandemic, resulting in non-significant widening of the Black-White disparity from aRR 2.51 (95%CI: 1.53-4.16) to aRR 4.07 (95%CI: 1.56-12.01) (interaction P = 0.41). No findings replicated in New Haven.

CONCLUSION: We detected no overall pandemic effects on PTB, but potential indirect benefits for some patients which could widen disparities remains possible.

DOI

10.1038/s41372-022-01488-1

Alternate Title

J Perinatol

PMID

35974082

Title

The Uptake of Telemedicine in Obstetric Care During the Early Acute Phase of the Coronavirus 2019 Pandemic.

Year of Publication

2022

Date Published

09/2022

ISSN Number

1556-3669

Abstract

The early acute phase of the coronavirus disease 2019 pandemic created rapid adaptation in health care delivery. Using electronic medical record data from two different institutions located in two different states, we examined how telemedicine was integrated into obstetric care. With no telemedicine use prior, both institutions rapidly incorporated telemedicine into prenatal care (PNC). There were significant patient-level and institutional-level differences in telemedicine use. Telemedicine users initiated PNC earlier and had more total visits, earlier timing of ultrasounds, and earlier diabetes screening during pregnancy compared with nonusers. There were no significant differences in delivery mode or stillbirth associated with telemedicine use at either institution. Rapid adoption of obstetric telemedicine maintained adequate prenatal care provision during the early pandemic, but implementation varied across institutions.

DOI

10.1089/tmj.2022.0291

Alternate Title

Telemed J E Health

PMID

36067146

Title

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial.

Year of Publication

2022

Date Published

09/2022

ISSN Number

1468-2052

Abstract

OBJECTIVE: To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.

DESIGN: Single-arm, non-randomised, feasibility trial.

SETTING: Three centres in the Children's Hospital of Philadelphia neonatal care network.

PATIENTS: Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO) >0.25 on CPAP of 4-7 cm HO.

INTERVENTIONS: We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%.

MAIN OUTCOME MEASURES: Within-subject change in V'/Q' mismatch between baseline and best CPAP levels.

RESULTS: There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm HO.

CONCLUSIONS: Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.

TRIAL REGISTRATION NUMBER: NCT02983825.

DOI

10.1136/archdischild-2022-324474

Alternate Title

Arch Dis Child Fetal Neonatal Ed

PMID

36104165

Title

Regionalization of neonatal care: benefits, barriers, and beyond.

Year of Publication

2022

Date Published

2022 Apr 23

ISSN Number

1476-5543

Abstract

<p>The goal of regionalization of neonatal care is to improve infant outcomes by directing patients to hospitals where risk-appropriate care is available. Although evidence shows that regionalized, risk-appropriate neonatal care decreases mortality, especially for high-risk infants, the approach and success of regionalization efforts in the U.S. and around the world is highly variable. Barriers to regionalization exist on the patient, provider, hospital, state, and national levels, which highlight potential opportunities to improve regionalization efforts. Improving neonatal regionalized care delivery requires a collaborative approach inclusive of all stakeholders from patients to national professional organizations, expansion and adaptation of current policies, changes to financial incentives, cross-state collaboration, support of national policies, and partnership between neonatal and obstetric communities to promote comprehensive, regionalized perinatal care.</p>

DOI

10.1038/s41372-022-01404-7

Alternate Title

J Perinatol

PMID

35461330

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