Perinatal Regionalization and Quality of Care

描述（由申请人提供）：出生体重低于1500克的极低出生体重婴儿（VLBW）是一个重大的公共卫生问题，每年有57,000名婴儿出生，医疗保健费用超过40亿美元。已经制定了区域化政策，以优化对这些高风险新生儿的护理，将对极低体重婴儿的护理集中在特定地理区域内的几家专科医院。然而，这些政策最近在美国的许多地区都有所减弱。这些政策变化如何影响新生儿护理质量和患者安全尚不清楚，因为之前的工作受到以下因素的限制：(1)选择偏差；(2)混合病例严重程度控制不佳；(3)缺乏统一的区域化程度衡量标准。为了解决这些方法学问题，本提案将使用工具变量方法来回答以下具体目标：(1)量化医院之间新生儿护理质量的差异；(2)确定围产期去区域化对VLBW婴儿死亡率、抢救失败率、并发症和21天再入院率的影响；(3)建立预测模型，将新生儿结局解释为特定地理区域新生儿护理质量和区域化政策的函数。该项目将使用1992年至2002年三个州的人口数据，这些州每年估计有12,800名超生婴儿出生。两阶段回归技术将用于控制测量的混杂因素，而各种工具，包括从住宅邮政编码到区域中心和到最近的分娩医院的差分旅行时间将用于控制未测量的偏差。该研究将有助于发现新生儿结局的微小差异，并确定区域化政策对新生儿护理质量的影响，并且比以前的工作偏差更小。这项研究的结果将允许决策者在考虑到医院质量和人口的地理差异后，为各个地区制定围产期区划政策，提高对VLBW婴儿的护理质量和安全性。向这一高危婴儿群体提供的新生儿护理质量的改善，应该会在短期和长期内改善公共卫生、结果和照顾VLBW婴儿的医疗相关费用。

DESCRIPTION (Provided by Applicant): Very-low-birth weight (VLBW) infants with a birth weight less than 1500 grams are a significant public health concern, comprising 57,000 deliveries per year at a cost of over 4 billion dollars for medical care. Regionalization policies have been developed to optimize the care of these high-risk newborns, centralizing the care of VLBW infants at a few specialized hospitals within a defined geographic region. However, these policies have recently weakened in many areas of the US. How these shifts in policy have affected the quality of neonatal care and patient safety is unknown, since prior work has been limited by (1) selection bias; (2) poor control of casemix severity; and (3) the lack of a uniform measure of the degree of regionalization in the areas of interest. To address these methodological issues, this proposal will use an instrumental variables approach to answer the following specific aims: (1) to quantify the difference in the quality of neonatal care between hospitals; (2) to determine the effect of perinatal de-regionalization on the rates of mortality, failure-to-rescue, complication, and 21-day readmission in VLBW infants; and (3) to develop a predictive model that explains neonatal outcomes as a function of the quality of neonatal care and regionalization policy in a given geographical area. This project will use population data from the years 1992 to 2002 in three states that have an estimated 12,800 VLBW births per year. Two-stage regression techniques will be used to control for measured confounders, while various instruments including the differential travel time from the residential zip code to regional center and to the nearest delivery hospital will be used to control for unmeasured bias. The study will be powered to find small differences in neonatal outcomes and determine the effect of regionalization policies on neonatal quality of care with less bias than previous work. Results from this study will allow policy makers to develop perinatal regionalization policies for individual areas after accounting for geographic differences in hospital quality and population, improving the quality and safety of care for VLBW infants. This improvement in the quality of neonatal care delivered to this high-risk population of infants should result in short and long-term improvements in the public health, outcome, and medical-related costs of caring for VLBW infants.