ILLNESS SEVERITY & PRACTICE VARIATION AMONG NEWBORN ICUS

新生儿重症监护室（NICU）是一个非常有效的 然而，在死亡率、发病率和死亡率方面， 资源利用 尽管这种变化可能代表着 在NICU人群中，调整出生体重、种族和外生儿 地位降低，但不能消除它。 这些差异是否是由于疾病的严重程度或 NICU技术应用不佳。 无直接是否 由于缺乏经验证的严重度指数， 新生儿重症监护 我们最近已经证明， 可以测量疾病的严重程度，并使用新验证的评分 新生儿急性生理学（SNAP），并量化医疗资源使用 新生儿治疗干预评分系统（NTISS） 我们假设，控制入院疾病的差异 NICU之间的严重程度将消除一些，但不是所有NICU差异 结果。 具体来说，我们预计死亡率不会有任何差异 但是新生儿重症监护室的并发症，如支气管肺发育不良， (BPD新生儿慢性肺病）、脑室内出血（IVH）， 练习风格。 此外，我们预计，治疗强度和 停留时间（以及由此推断的费用）将明显不同， 积极或保守的实践风格。 我们的目标是证明 NICU间差异的数量可归因于 人口风险（出生体重和疾病严重程度）以及 实践风格的差异。 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） 疾病的多中心前瞻性队列研究中的资源使用 2个相邻州的7个NICU的严重程度。 我们将招收新生儿 2年内出生体重1500克，预计总计2000克， 300人死亡 研究人员将评估疾病严重程度和资源 分别使用SNAP和NTISS在第1、3和14天使用。 我们还将 收集住院时间（LOS）和4种选定的发病率、BPD、IVH、NEC 和院内菌血症。 对于每个结果，我们将记录差异 i新生儿重症监护病房的粗发病率，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）。 持久性 变化将提供有效性差异的证据 NICU "套餐""进一步调整已知治疗相关风险 因素（侵入性导管、机械通气等）将确定 结果差异的来源。 第二组分析将 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。 剩余变化到期日 并发症发生率和出院政策的差异， 记录在案。 最后，我们将深入分析5个选定的 技术的无效应用或过度使用的证据。 本研究的意义将是重要的示范 发病率和医疗资源使用的机构间差异 不能归因于NICU人群或严重程度的差异 疾 这将有助于努力改善成果， 通过针对性的技术或做法进行有效性试验来降低成本 或效率。

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.