Perinatal Regionalization and Quality of Care

描述(申请人提供)：出生体重低于1500克的极低出生体重(VLBW)婴儿是一个重大的公共卫生问题，每年有57,000名婴儿出生，医疗费用超过40亿美元。已经制定了区域化政策，以优化对这些高危新生儿的护理，将极低出生体重儿的护理集中在特定地理区域内的几家专门医院。然而，这些政策最近在美国的许多地区都有所减弱。政策的这些转变如何影响新生儿护理的质量和病人的安全尚不清楚，因为先前的工作受到以下因素的限制：(1)选择偏见；(2)对病例严重性的控制不力；(3)在感兴趣的领域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)量化不同医院之间新生儿护理质量的差异；(2)确定围产期非区域化对极低出生体重儿死亡率、抢救失败、并发症和21天再入院的影响；(3)开发一个预测模型，解释特定地理区域的新生儿护理质量和区划政策对新生儿结局的影响。该项目将使用1992年至2002年三个州的人口数据，这三个州估计每年有12,800名极低出生体重婴儿出生。两阶段回归技术将用于控制已测量的混杂因素，而各种工具，包括从住宅邮政编码到区域中心和最近的送货医院的差异旅行时间将用于控制未测量的偏差。这项研究将有能力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，而偏见比以前的工作更少。这项研究的结果将使政策制定者在考虑到医院质量和人口的地理差异后，为个别地区制定围产期区划政策，提高极低出生体重儿的护理质量和安全性。向这一婴儿高危人群提供的新生儿护理质量的这种改善，应该会导致照顾极低出生体重儿的公共卫生、结果和医疗相关成本的短期和长期改善。

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.