ILLNESS SEVERITY & PRACTICE VARIATION AMONG NEWBORN ICUS

疾病严重程度

• 批准号: 2235887
• 负责人: DOUGLAS K RICHARDSON
• 金额: $ 100.08万
• 依托单位: BETH ISRAEL DEACONESS MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 1994
• 资助国家: 美国
• 起止时间: 1994-04-01 至 1998-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/2235887
• 关键词: ILLNESS; SEVERITY; PRACTICE; VARIATION; AMONG

Neonatal Intensive Care Units (NICUs) represent a very effect array of technologies, yet marked variation is evident in mortality, morbidity and resource utilization. Although this variation may represent differences in NICU populations, adjustments for birth weight, race, and outborn status reduce but do not eliminate it. It is important to distinguish whether these differences are due to severity of illness or to ineffective application of NICU technologies. No direct whether comparison have been performed due to lack of validated severity indices for neonatal intensive care. We have recently demonstrated that it is possible to measure illness severity and using the newly validated Score for Neonatal Acute Physiology (SNAP) and to quantify medical resource use using the Neonatal Therapeutic Intervention Scoring System (NTISS). We hypothesize that controlling for difference in admission illness severity between NICUs will eliminate some, but not all NICU differences in outcome. Specifically we anticipate no differences in mortality rates but that rates of NICU complications such as bronchopulmonary dysplasia (BPD, neonatal chronic lung disease), intraventricular hemorrhage (IVH), practice styles. Moreover we expect that therapeutic intensity and length of stay (and by inference costs), will vary markedly reflecting aggressive or conservative practice styles. Our goals are to demonstrate the amount of inter-NICU variation attributable to differences in population risk (birth weight and illness severity) and that due to differences in practice style. A second goal is to identify variation in practice that may increase costs without improving outcomes. We propose to examine variations in 1) mortality, 2) morbidity and 3) resource use in a multi-center prospective cohort study of illness severity among 7 NICUs in 2 adjacent states. We will enroll an newborns 1500 gm birth weight during a 2-year period, expected to total 2000, and 300 deaths. Study personnel will assess illness severity and resource use on days 1, 3, and 14 using SNAP and NTISS respectively. We will also collect length of stay (LOS) and 4 selected morbidities, BPD, IVH, NEC and nosocomial bacteremia. For each outcome we will document differences i crude incidence rates among NICUs,and then adjust for baseline population risk (birth weight, sex, race, illness severity). Persistent variation will provide evidence of differences in effectiveness of the NICU "package" "Further adjustment for known treatment-related risk factors (invasive catheters, mechanical ventilation, etc.) will identify the sources of disparity in outcomes. A second set of analyses will focus on variations in length of stay (LOS) and medical resource use when adjusted for birth weight and illness severity. Residual variation due to differences in complication rates and discharge policies will be documented. Finally, we will perform in depth analyses of 5 selected technologies for evidence of ineffective application or excessive use. The significance of this research will be the demonstration of important inter-institutional variation, in morbidity, and medical resource use that cannot be attributed to differences in NICU populations or severity of illness. This will facilitate efforts to improve outcomes and to reduce cost by targeting technologies or practices for trials of efficacy or efficiency.

新生儿重症监护病房(NICU)代表了一系列非常有效的 技术，但明显的变化是死亡率，发病率和 资源利用率。尽管这种变化可能代表不同 在NICU人群中，对出生体重、种族和出生儿进行调整 地位会降低，但不会消除。重要的是要区分 这些差异是由于疾病的严重程度还是由于 NICU技术应用不力。不知道是否直接 由于缺乏经过验证的严重性指数，已执行了比较 用于新生儿重症监护。我们最近证明了这一点 可以测量疾病严重程度，并使用新验证的分数 用于新生儿急性生理学(SNAP)和量化医疗资源使用 使用新生儿治疗干预评分系统(NTISS)。 我们假设，控制住入院疾病的差异 NICU之间的严重程度将消除部分但不是所有NICU差异 在结果中。具体地说，我们预计死亡率没有差异 但NICU并发症的发生率，如支气管肺发育不良 (BPD，新生儿慢性肺病)，脑室出血(IVH)， 练习风格。此外，我们预计治疗强度和 停留时间(以及推论成本)将明显不同，反映出 激进或保守的练习风格。我们的目标是证明 NICU间的变异量可归因于 人口风险(出生体重和疾病严重程度)以及 练习风格上的差异。第二个目标是识别变异 在实践中，这可能会增加成本，而不会改善结果。 我们建议检查1)死亡率、2)发病率和3) 多中心前瞻性队列疾病研究中的资源利用 两个相邻州的7个NICU之间的严重程度。我们将招收一名新生儿 在两年内出生体重1500克，预计总数为2000克，以及 300人死亡。研究人员将评估疾病的严重性和资源 分别在第1天、第3天和第14天使用SNAP和NTISS。我们还将 收集住院时间(LOS)和4种选定的疾病、BPD、IVH、NEC 和医院内菌血症。对于每个结果，我们将记录差异 I NICU中的粗发病率，然后根据基线进行调整 人口风险(出生体重、性别、种族、疾病严重程度)。持久化 差异将提供证据，证明 NICU“一揽子计划”进一步调整已知的治疗相关风险 因素(有创导管、机械通气等)将确定 结果不一致的根源。第二组分析将 重点关注住院时间(LOS)和医疗资源使用的变化 根据出生体重和疾病严重程度进行调整。剩余差额到期 并发症发生率和出院政策的差异将是 有记录在案。最后，我们将对所选的5个案例进行深入分析 用于证明无效应用或过度使用的技术。 本研究的意义将在于论证具有重要意义的 发病率和医疗资源使用方面的机构间差异 这不能归因于NICU人群或严重程度的差异 疾病的威胁。这将有助于努力改善结果和 通过针对疗效试验的技术或实践来降低成本 或者效率。