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					Toward Achieving “Better” Practices
Regional Forums & Data Analysis
Edmund F. La Gamma, M.D. Chief, Division of Newborn Medicine Director, Neonatal-Perinatal Fellowship Program Professor of Pediatrics, Biochemistry & Molecular Biology

Economic Impact of Perinatal Health Care
United States - Y2001
Long Term Impact! 12% of VLBW’ 100% Will have Cerebral Palsy 80% With a Prorated Lifetime Cost of $1 million/pt 60%
40% 46% 8%

Prematurity/LBW

All Other

54% 92%

20%

8% of All Births Utilize 46% of Neonatal Health Care Dollars

0%

Prematurity/LBW All Other Total

Discharges 384,000 4,227,000 4,611,000

Total Charges $13,593,724,000 $15,699,376,000 $29,293,100,000

Excludes stays with charges greater than $1 million. Source: Agency for Healthcare Research and Quality, 2001 Nationwide Inpatient Sample Prepared by March of Dimes Perinatal Data Center, 2003

What is the Core Problem In “Public” Health Care

Calculating the “Value” of Medical Services

Quality of Care

Value =
Cost of Service

The Cost of the “Highest” Quality of Care
*** The “Zagat Survey” of Health Care *** *
100%’ile

Hospital B Hospital A
50%’ile

Effort or Cost or People Required to Accomplish Goal * If no significant factual difference - “B” is at risk of bankruptcy ! ?

What’s Really on Everyone’s Mind

Do We Truly Know What Rx Is Best ?

Don’t We Risk Making the Whole Health Care System One Large Public Health Experiment And then… Losing The Trust of Our Patients as Individuals ?

Can we do better?

The New Perinatal Health Code System – Y2005

DOH
Stakeholders

RPC MFCH RPF SPDS
Data collection

RPC PN Hospitals Health Dept Insurers PCAP MOMS March of Dimes

Medical QA
NE SW

Co-Chair RPC

PN Co - Chair

NW

SE

Steering Committee

Quality of Care Best practices Education

Report card/ Benchmarking Transport

Access to care Birth outcomes Breastfeeding Pt Education

WIC
Lactation Others

Regionalization Enables Novel Services That Can’t Be Replicated Everywhere “Economies of scale – develop & maintain all options”
Ventilation – all forms immediately available -high frequency oscillators -jet ventilation -assist-control conventional ventilation Cardiovascular -nitric oxide -ECMO program -neonatal heart surgery CNS -head cooling/asphyxia Clinician Experience: Competence & Availability for Rare problems

How does the Lower Hudson Valley Look ?

Population Growth in New York State
Population New York State Y2000 Y2004 18,998,700 19,227,100 Up 1.2 %

Hudson Valley *

Y2000 Y2004

2,185,700 2,258,300

Up 3.3 %

*The Hudson Valley ranks first among the ten regions in NYS for population growth.

What are the Birth Demographics for the Hudson Valley ?
All NYS Births 278,000 249,947 Y1997 Y2005 Down 10%

Hudson Valley Regional Births (21 Hospitals)

23,303 25,392

Y1997 Y2005

Up 9%

VLBW/ELBW Neonates in Valley

332 (1.4 %) Y1997 378 (1.5 %) Y2005

Up 14%

Where are the Births ?
% Birth by County
(n = 29,932 annual births)

Orange 17% Sullivan 3% Ulster 6% Dutchess 11% Putnam 4%

Westchester 44%

Rockland 15%

New York Vital Statistics 2003

Is Regionalization Having an Impact in the Hudson Valley?

Source: EBC Data 2006

Concentrating Rare Problems
Requiring Large Efforts in One Place -Very Low Birth Weight ~1 % ( ~3 lbs or 1500g or < 32 wks) -Extreme Prematurity < 0.5 % ( < 2 lbs or < 1000g or < 28 wks)

Evidence for Impact of Regionalized Services
Last Three Years of Change

3
2 1

Source: SPDS- NICU Module 2004- 2006

Incidence of Malformations
3.4% of all births in NYS (9,452/yr)

Hudson Valley Y1997 Y2005

885 965

80% of Malformations are a single lesion 75% of Malformations are diagnosed < 3 days postnatal age

Utilization of Specialized Services Over Time
RPC Hospitals 1997 vs. 2005 SPARC's Data
Y1997 = 23,303 vs. Y2005 = 25,392 total births

Represents Y1997 = 0.45% 80 Y2005 = 0.43% 70 of all Births
60

% All Regional Cases at WMC Y1997 = 105 Y2005 = 109 % All NICU DRG's in Region Y1997

= 3129 - 13.4%

Y2005 = 3685 - 14.5%
Y1997 = 2035 Y2005 = 2531

Percent

50 40 30 20 10 0
<1.0

Y1997 = 227 Y2005 = 160 Y1997 = 371 Y2005 = 369

Y1997 = 391 Y2005 = 516

Y1997 = 8.7% Y2005 = 10.0% of all Births Primarily: Malformations Sepsis/PPHN Meconium Asp Late Preterm
>2.5

1.0-1.5

1.5-2.0

2.0-2.5

Weight in Kg

Late Preterm Neonates Consume Large Quantities of Aftercare and Need Follow-up Interventions
< 32 wks
32-33 wks
Y2004

Late Preterm’s

34 – 36 Weeks Percent Preterm in USA
70% of All Preterm Births Are Late Preterm (34-36 weeks gestation)
www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdf Kalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007

Acknowledgements
Regional Perinatal Center
Edmund La Gamma, MD Heather Brumberg, MD Susan Marchwinski, RN, MS Donna Dozor, RN, MS Kathy Rogan, RN Clare Nugent, RN Tania Mangones, MD C. D. Hsu, MD, MPH Paul Visintainer PhD

Perinatal Networks
Cheryl Hunter-Grant, LMSW Marilyn Serbetzian, RN, NP Annette Lopez-Kendra, RN Caren Fairweather, MPS Stephanie Sosnowski, ICCE

March of Dimes Perinatal Data Center
Joann Petrini, PhD, MPH Tomoko Kushnir
Regional Perinatal Forum Steering Committee for their ongoing time, effort and dedication to developing our regional perinatal health initiative

Thank

You !

Percentage Change in Birth Weight in USA 1990 vs. 2004

Fewer Post-Term

More Preterm

Communicating With and Educating Consumers
Lower Hudson Valley Perinatal Network
% Birth by County
(n = 29,932 annual births)
Orange 17% Sullivan 3% Ulster 6% Dutchess 11%

Previously Just 26% Births had Access to Perinatal Networks

Westchester 44%

Newly Funded Perinatal Network Y2006

Rockland 15%

Putnam 4%

New York Vital Statistics 2003

Source: SPDS- NICU Module 2006

*Total discharged home excludes inhouse transfers

The Value of Cooperativeness THE REGIONAL NEONATAL CENTER
ADMISSIONS 1989-1999
800 700 600 500 400 300 200 100 0 89 90 91 92 93 94 95 96 97 98 99

YEAR OF ADMISSION
< 1000 g 1001-2000 G > 2000 g

Growth of Community Level II & III

Source: 2006 SPDS

What Type of Malformations in NYS ? (42,500 births in our catchment area)
Cardiovascular > Genitourinary > Musculoskeletal >> Chromosomal
26% VSD ASD Valves 19% Hypospadias Obstructive 18% Hip Dislocation Club Foot ~3% Trisomy 21 (66% of all)

General Surgical per ~42,5000 births in Hudson Valley

GI Obstructions Gastroschisis/Omphalocele Congenital Diaphragmatic Hernia
Total

69 cases/yr 18 cases/yr 11 cases.yr 98 case/yr

Impact of Malformations on Pediatric Health Care
Morbidity due to Malformations
33% of all pediatric in-patient days ! 25% of all pediatric hospital admissions ! 75% are defined in the first 3 days after birth 80% are a single lesion

Mortality in Pediatrics
5% perinatal-neonatal (LBW/RDS) 25% congenital malformations 20% SIDS

Source: EBC Data 2006

Source: 2006 SPDS

Prevalence of Births/Malformations in Hudson Valley Hospitals: Y1997 & Y2005
Region Births ELBW
(<1500g; 1.4%)

Malformations*
(3.8%)

Hudson Valley Y1997
Y2005

23,303 25,392

332 378

885 965

Westchester Orange Rockland Putnam

12,866 4,869 4,341 1,227

176 66 52 23

488 185 165 47

80% of Malformations are a single lesion and 75% are diagnosed < 3 days postnatal age

The Impact of Highly Experienced and Skilled Clinicians
Incidence of Chronic Lung Disease in <1000g
60

Vermont-Oxford 1997
50

46% (3970/8672)

Percentage

40

30

22%(13/60)
20

BPD Rate is Among Lowest in Nation

13%(8/59)

10

0

Vermont Oxford

1

PRE

2

3 Post

4

July 1999
Decreased incidence of CLD disease using “Optimal FRC Strategy ” to 13% as compare to Pre-July group(22%) & Vermont-Oxford data(46%). 5/15 Pt on HFV developed CLD in Post-July group
Zia et al Ped Res 51(4): A 2279, 2002


				
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