EVIDENCE-BASED SELECTIVE REFERRAL IN VLBW INFANTS

描述(由申请人提供)：极低出生体重(VLBW)婴儿(出生时低于1500克)的医疗护理过程和结果在不同的新生儿重症监护病房(NICU)之间存在显著差异。即使在对患者风险进行适当调整后，死亡率和发病率仍存在显著差异。出生体重极低的婴儿是高危患者群体，每年占美国婴儿死亡人数的46%。循证选择性转诊有可能改善这些脆弱婴儿的预后。然而，目前的标准(由LeapFrog Group制定)在NICU护理这些婴儿方面存在几个潜在问题：(1)它没有考虑到护理质量的多维度；(2)它只基于提供者的数量。在这个项目中，我们建议： 1)通过回答以下问题，改善选择性转诊极低出生体重儿的证据基础： -体积作为影响极低出生体重儿的广泛医疗结果的间接质量指标有多好？在与极低出生体重儿死亡率和发病率相关的广泛结局指标中，体量的系统差异能解释多少？ -还有什么其他间接质量指标，与体量相结合，可以更好地解释极低出生体重儿结局指标的差异？ 2)通过回答以下问题，评估选择性转介的替代办法： -对于极低出生体重儿，使用体量或替代质量指标作为选择性转诊的基础，对婴儿死亡率和发病率有何影响？ -更好的结果与家庭的治疗费用和旅行时间有什么权衡？ 这项研究将使用佛蒙特州牛津网络(VON)的数据和加州的关联流量摘要和生命统计数据。VON每年包含美国40%的NICU和一半的VLBW新生儿。在所有州中，加利福尼亚州每年出生的婴儿总数和极低出生体重婴儿数量最多。

DESCRIPTION (provided by applicant): The processes and outcomes of medical care for very low birth weight (VLBW) infants (under 1500 grams at birth) vary markedly among different neonatal intensive care units (NICUs). Substantial variation in both mortality and morbidity remain even after appropriately adjusting for patient risk. Infants with very low birth weights are a high risk patient population, accounting for 46 percent of infant deaths in the US each year. Evidence-based selective referral has the potential to improve outcomes for these fragile infants. However, the current standard (set by the Leapfrog Group) has several potential problems for NICU care of these infants: (1) it does not take into consideration the multidimensionality of quality of care and (2) it is based only on provider volume. In this project, we propose to: 1) Improve the evidence base for selective referral of VLBW infants by answering the following questions: - How good is volume as an indirect quality indicator for a broad range of medical outcomes affecting VLBW infants? How much systematic variation does volume explain in a broad range of outcome measures related to mortality and morbidity for VLBW infants? - What other indirect quality indicators, in combination with volume, could better explain the variation in outcome measures for VLBW infants? 2) Evaluate alternative approaches to selective referral by answering the following questions: - What are the implications for infant mortality and morbidity of using volume versus alternative quality measures as the basis for selective referral for VLBW infants? - What are the tradeoffs of better outcomes with treatment costs and travel times of families? The study will use data from the Vermont Oxford Network (VON) and linked discharge-abstract and vital statistics data for California. VON contains 40% of the NICUs in the US and half of all VLBW births in the US each year. Of all states, California has the largest number of total births and VLBW infants born in the country each year.