Perinatal Regionalization and Quality of Care

描述（由申请人提供）：出生体重小于1500克的极低出生体重（VLBW）婴儿是一个重要的公共卫生问题，包括每年57，000例分娩，医疗护理费用超过40亿美元。制定了区域化政策，以优化对这些高危新生儿的护理，将极低出生体重婴儿的护理集中在确定的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有所减弱。这些政策的转变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）选择偏倚;（2）病例组合严重程度控制不佳;（3）缺乏对感兴趣领域区域化程度的统一衡量。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极低出生体重儿死亡率、抢救失败率、并发症率和21天再入院率的影响;以及（3）开发一个预测模型，将新生儿结局解释为给定地理区域内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，估计每年有12 800名极低出生体重儿出生。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最近的分娩医院的旅行时间差将用于控制未测量的偏倚。这项研究将有能力找到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，其偏倚比以前的工作要小。这项研究的结果将使政策制定者在考虑医院质量和人口的地理差异后，为个别地区制定围产期区域化政策，提高VLBW婴儿护理的质量和安全性。这种新生儿护理质量的提高，提供给这一高风险的婴儿群体，应导致在公共卫生，结果和医疗相关的成本照顾极低出生体重婴儿的短期和长期的改善。

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.