The impact of managed clinical networks on place of birth and newborn transfersChris Gale

On behalf of the Neonatal Data Analysis Unit and the Medicines for Neonates Investigator Group

Background

Neonatal services reorganised in 2003 into managed clinical networks

• Increase provision of high quality neonatal care

No formal mechanism established to evaluate the impact of reorganisation on patient care

Among preterm infants:• Delivery and initial care at specialised units is associated with

improved outcomes (Lasswell 2010)

• Acute postnatal transfer is associated with adverse outcomes (Mohamed 2010, Towers 2000)

Reflected in key aims of 2003 reorganisation

Amenable to evaluation

Aims

Use data, routinely collected by units, to evaluate the effectiveness of reorganisation in managed clinical networks

Before and after analysis of the following outcomes:

1. Proportion of preterm babies delivered in neonatal units with the greatest neonatal intensive care experience

2. Proportion of preterm babies undergoing early transfer: before 24 hours of age

3. Proportion of preterm babies undergoing late transfer: between 24 hours and 28 days

4. Proportion of multiple birth sets separated by postnatal transfer

Study design

Epoch 1: Before reorganisation• Extracted from CESDI Project

27/28 • 1st September 1998 to 31st

August 2000• Babies born alive at 27/28

gestational weeks

Epoch 2: After reorganisation • Your data!• 1st January 2009 to 31st

December 2010• Babies admitted to a neonatal

unit at 27/28 gestational weeks

1998 2000 2002 200820062004 2010

Epoch 1 Epoch 2

Reorganisation

Data analyses

Differences between epochs:

Level of neonatal unit at hospital of birth and transfer status • χ2 test

Dichotomous outcomes: Level of neonatal unit at hospital of birth (≥2000 vs <2000) and multiple birth sets separated by transfer

• Risk difference (RD) [95% Confidence Intervals]• Odds ratio (OR) [95%CI]

Results

Epoch 1: Before reorganisation• 294 centres providing maternity care• No standard definition of neonatal unit level• 148 providing >48 hours of ventilation• 3522 babies between 27 weeks+0 days to 28 weeks+6 days

Epoch 2: After reorganisation • Data from 146 of 173 neonatal units in 23 neonatal networks• 34 level one, 72 level two, 40 level three units• 2919 babies between 27 weeks+0 days to 28 weeks+6 days

No clinically important differences in demographic characteristics between epochs

Results: Place of birth

Epoch 1 Epoch 2 p-value

DaysNumber of babies

% of total

Number of babies

% of total

Hospital of birth categorised by annual number of neonatal intensive care days

None 139 4.0 0 0

<0.001

1-499 843 24.1 331 12.2

500-999 673 19.3 465 17.1

1000-1499 653 18.7 316 11.6

1500-1999 556 15.9 287 10.5

≥ 2000 631 18.1 1325 48.6

Missing 27 - 195 -

Total 3522 2919

Proportion delivered in at hospitals with the highest activity NICU increased significantly:

•RD of 31% [28%, 23%], OR 4.3 [3.83, 4.82]

Categorisation of neonatal units in epoch 2

Annual number of neonatal intensive care days provided in epoch two

Number of neonatal units Number of neonatal units (% of total)

Level 1 neonatal unit

Level 2 neonatal unit

Level 3 neonatal unit

≤499 32 23 0 55 (38%)

500-999 2 29 1 32 (22%)

1000-1499 0 12 4 16 (11%)

1500-1999 0 5 6 11 (8%)

≥2000 0 3 29 32 (22%)

Total 34 72 40 146 (100%)

Results: Transfers

Epoch 1 Epoch 2 p-value

Transfer statusNumber of babies

% of total

Number of babies

% of total

Transfers

Not transferred 2434 74.9 1919 65.7

<0.001

≤ 24 hours 235 7.2 360 12.3

24 hours-28 days 579 17.8 640 21.9

Missing 0 - 0 -

Total 3248 2919

Significantly greater proportion of babies undergoing both acute and later postnatal transfer between epochs

125

75

50

25

0

100

Postnatal age (days)

To higher level unitTo lower level unitTo equivalent unit

Transfers in epoch 2

Results: Multiple births separated

No significant difference detected between epochs• RD 3% [-15%, 8%]• OR 0.86 [0.50, 1.46]

Epoch 1 Epoch 2 p-value

Multiple birth sets separated by transfer

Number of birth sets

% of total

Number of birth sets

% of total

Not separated 80 67.2 91 70.5

0.57Separated 39 32.8 38 29.5

Total 119 129

Limitations and strengths

Limitations• Association between reorganisation and outcomes• Aggregated data only for epoch one• Unable to analyse underlying trends in outcomes

Strengths• Large numbers• National distribution of units in both epochs• Unambiguous, clearly defined outcomes• Epoch two represents current state of neonatal care in England

Summary

Following reorganisation1. Increase in proportion of babies delivered at high volume units

• In keeping with a key aim of reorganisation

• Over half of babies still delivered at lower volume neonatal units

• Room for improvement

2. Increase in acute transfers• Key aim of reorganisation not being met

• 1 in 8 babies undergo transfer within first day: 30% to an equivalent or lower level unit

• Multiple birth sets continue to be separated by transfer

• Cot capacity impacting on clinical care

• Better understanding of the clinical implications transfers

Acknowledgements

Clinicians and other health professionals contributing high quality data

Neonatal Data Analysis UnitShalini Santhakumaran Eugene Statnikov

Sridevi Nagarajan

Imperial College London Academic Neonatal Medicine

NDAU Steering BoardJane Abbott Jacquie Kemp

Peter Brocklehurst Azeem Majeed

Kate Costeloe Neena Modi

Liz Draper Alys Young

Deborah Ashby Andrew Wilkinson

Stavros Petrou

Survival

Epoch 1 Epoch 2

p-value for difference between epoch 1 and 2

Number of babies

% of total

Number of babies

% of total

Survival at 28 days

Survived 2859 88.0 2677 93.6

<0.001Died 389 12.0 182 6.4

Missing 0 - 60 -

Total 3248 2919

Significantly higher survival in England in epoch 2 vs epoch 1• RD 5.6% [4.2%, 7.0%], OR 2.00 [1.67, 2.40], p<0.001