ANGELS Does it Work Whit Hall MD

ANGELS: Does it Work? Whit Hall MD

ANGELS Education n Guidelines n n Referral n Arkansas, a rural state n 3 areas with practicing neonatologists n Other areas with pediatricians

ANGELS: Education Monthly teleconference meetings n Face to face interaction n Two way street n AHEC contribution n

ANGELS: Guidelines n Buy-in to guidelines Apnea n Pain n Hyperbilirubinemia, etc n Published in AMJ n Contribution of practicing physicians (e. g. , recommendation on apnea) n Evidenced based n

ANGELS: Regionalization Better communication n “Town gown” gap narrowed n More appropriate (not necessarily more) referrals n Is it a good thing for the preterm neonate? ? n

Regionalization: History Improved outcomes in Wisconsin (Graven, 1977) n Improved outcomes in Canada (Sankaran K, 2002) n Improved rates of IVH Canada (Synnes a, 2002) n Improved outcomes in AR (Kirby, 1995, Palmer, Hall RW, n 2005)

Maternal referral n Numerous articles attesting to that Improved outcomes in IVH in California (Towers C, 2000) and Kansas (Hall Robert, 2003) n Improved mortality outcomes in perinatal Canadian centers compared to free standing children’s hospitals (Shah P, 2005) n Decreased disability (Victorian Study Group, 1991) n n Decreased mortality (Kollee, 1999; Warner, 2004; Lubchenco, 1989; Yeast, 1998; Cooper, 1999 Obladen, 1994; Johansson, 2004; Gerlinde, 2005)

But…. n Higher mortality at night in inborn units n n n Better (40%!) if in-house fellow or attending (Lee, SK, 2003) Observed mortality lessin hospitals without residency programs and lessvolume (104 vs. 62) (Horbar JD, 1997) Outborn status protective in US Centers (NEOPAIN trial, Rao R, Hall RW, 2006) n No difference in mortality after adjusting for prenatal steroids (NEOPAIN trial, Palmer KG, Hall RW, 2005) n NEOPAIN trial required transfer within 7 hours

Problems with Maternal Transport in Arkansas Rural state with long distances to travel in preterm labor n Home for threatened preterm labor not well developed n Evolving transport system with established neonatal transport system n Hospital competition n n Money, pride, prestige

Summation of literature Overwhelming support for regionalization n Overwhelming support for maternal transport n IVH always decreased in inborn population n Selection bias a problem in all studies n Refer patients who are “survivable” n Outborn babies may require emergency delivery n n Abruption, Uterine rupture, prolapsed cord, etc

ANGELS: Referral Regionalization works n A neonatologist does not an intensive care nursery make n Hindrances to regionalization n Money n Prestige n n Why UAMS? ? ? Palmer, Hall, et al, 2005; Fanaroff & Martin, 7 th ed, 2002

Why We Started: Mortality Data from 1995 -2000 ACH p=0. 039 for 500 -600 gms Vt. Ox p<0. 001 for 500 -600 gms NICHD p<0. 001 for 500 -600 gms ACH p=0. 087 for 600 -700 gms Vt. Ox p=0. 02 for 600 -700 gms NICHD p<0. 005 for 600 -700 gms

Why We Started: Mortality Data From 19952000 ACH p=0. 0135 for 500 -750 Vt. Ox p<0. 0001 for 500 -750 NICHD p<0. 0001 for 500 -750 Vt Ox p=0. 0065 for 750 -1000 NICHD p=0. 026 for 750 -1000

Why We Started: IVH Data From 1995 -2000 500 -750 750 -1000 -1250 -1500 ACH p=0. 047 p=0. 33 p=0. 002 NICHD p<. 0001 p=. 0004 p=. 0261 p=0. 02 p=. 10

Evidence Better outcomes with inborn delivery in AR n Need for education n Medicaid deliveries n Large impact (55% coverage) n Easy to work with n Centralized n

Survival: 2001 -2004 ** * *p<0. 05 ** p<0. 01

Survival: 2001 -2004 *p<0. 05; **p<0. 01 ** *

Survival: 2001 -2004 **p<0. 01 ** ** * *

Survival: 2001 -2004 p<0. 01 UAMS vs. all others

Survival: 2001 -2004 P<0. 01 at all weights

Grade 3 and 4 IVH Rate * *p<0. 05 ** **p<0. 01

Why the Improved Outcomes at UAMS Maternal Transport n Strong OB/Perinatal program n ACH backup n Nursing experience n UAMS administration backup n In house neonatal coverage n Medicaid n

Number of UAMS VLBW Admissions ANGELS

What We Know UAMS has better survival in VLBW neonates n Less IVH in the inborn population n ANGELS has increased inborn delivery n Back-up of ACH n Medicaid is in a good position to advocate for better outcomes regardless of pride and prestige n

What We Must Research n Cost Initial hospital n Long term outcome and satisfaction of families n Quality of survival n

Conclusion n n ANGELS is building a better medical system IVH rates are markedly improved; survival is modestly affected in the system More research is needed on long term outcomes and costs ANGELS/Medicaid is a smart, cost effective system who cares for her clients, especially compared to other programs (FEMA) Funding should remain intact for AHRQ, Medicaid, and ANGELS