Edmund F. La Gamma, M.D.Edmund F. La Gamma, M.D.Chief, Division of Newborn Medicine Chief, Division of Newborn Medicine
Director, Neonatal-Perinatal Fellowship Program Director, Neonatal-Perinatal Fellowship Program Professor of Pediatrics, Biochemistry & Molecular BiologyProfessor of Pediatrics, Biochemistry & Molecular Biology
Toward Achieving “Toward Achieving “Better”Better” Practices Practices Regional Forums & Data AnalysisRegional Forums & Data Analysis
Economic Impact of Perinatal Health CareEconomic Impact of Perinatal Health CareUnited States - Y2001United States - Y2001
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
Prematurity/LBW 384,000 $13,593,724,000 All Other 4,227,000 $15,699,376,000 Total 4,611,000 $29,293,100,000
46%
92%
54%
8%0%
20%
40%
60%
80%
100%
Discharges Total Charges
Prematurity/LBW All Other
8% of All Births Utilize 46% of Neonatal Health Care Dollars
Long Term Impact!12% of VLBW’Will have Cerebral PalsyWith a Prorated Lifetime Cost of $1 million/pt
What is the Core What is the Core
Problem In Problem In
““Public” Public” Health CareHealth Care
Calculating the “Value” of Medical ServicesCalculating the “Value” of Medical Services
Quality of CareValue =
Cost of Service
The Cost of the “Highest” Quality of Care*** The “Zagat Survey” of Health Care ***
100%’ile
50%’ile
Effort or Cost or People Required to Accomplish Goal
*
* If no significant factual difference - “B” is at risk of bankruptcy ! ?
Hospital BHospital A
What’s Really on Everyone’s MindWhat’s Really on Everyone’s Mind
Do We TrulyKnow What RxIs Best ?
Don’t We Risk Making the Whole Health CareSystem One Large Public Health ExperimentAnd then…
Losing The Trust of Our Patients as Individuals ?
Can we do better?
DOH
RPCMFCH
Medical QA
SPDSData collection
RPF
NENW SE
SWCo-Chair
RPC PN
Co - Chair
Health Dept
Hospitals
PN
Steering Committee
RPC
Insurers
March ofDimes
Lactation
WIC
PCAP MOMS
Quality of CareBest practices
Education
Stakeholders
Report card/Benchmarking
Transport
Access to careBirth outcomesBreastfeedingPt Education
OthersOu
tco
mes
The NewThe NewPerinatal Perinatal Health CodeHealth CodeSystem – Y2005System – Y2005
Regionalization Enables Novel Services Regionalization Enables Novel Services That Can’t Be Replicated EverywhereThat Can’t Be Replicated Everywhere
““Economies of scale – develop & maintain Economies of scale – develop & maintain allall options” 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 forRare problems
How does the How does the Lower Hudson Valley Look ?Lower Hudson Valley Look ?
*The Hudson Valley ranks first among the ten regions in NYS for population growth.
Population
New York State Y2000 18,998,700
Y2004 19,227,100
Hudson Valley * Y2000 2,185,700
Y2004 2,258,300
Up 3.3 %
Up 1.2 %
Population Growth in New York StatePopulation Growth in New York State
What are the Birth DemographicsWhat are the Birth Demographicsfor the Hudson Valley ?for the Hudson Valley ?
All NYS Births 278,000 Y1997249,947 Y2005
Hudson Valley Regional Births 23,303 Y1997 (21 Hospitals) 25,392 Y2005
VLBW/ELBW Neonates in Valley 332 (1.4 %) Y1997 378 (1.5 %) Y2005
Down10%
Up 9%
Up 14%
Where are the Births ? Where are the Births ?
Westchester44%
Rockland15%
Putnam4%
Dutchess11%
Ulster6%
Sullivan3%
Orange17%
% Birth by County% Birth by County
(n = 29,932 annual births)(n = 29,932 annual births)
New York Vital Statistics 2003
Source: EBC Data 2006
Is Regionalization Having an Impact in the Hudson Valley?Is Regionalization Having an Impact in the Hudson Valley?
-Very Low Birth Weight ~1 %( ~3 lbs or 1500g or < 32 wks)
-Extreme Prematurity < 0.5 %( < 2 lbs or < 1000g or < 28 wks)
Concentrating Rare ProblemsConcentrating Rare Problems
Requiring Large Efforts in One Place Requiring Large Efforts in One Place
Source: SPDS- NICU Module 2004- 2006Source: SPDS- NICU Module 2004- 2006
Last ThreeYearsof Change
Evidence for Impact of Regionalized ServicesEvidence for Impact of Regionalized Services
11
22
33
Incidence of MalformationsIncidence of Malformations
3.4% of all births in NYS (9,452/yr)
Hudson ValleyY1997 885Y2005 965
80% of Malformations are a single lesion
75% of Malformations are diagnosed < 3 days postnatal age
Utilization of Specialized Services Over TimeUtilization of Specialized Services Over Time
RPC Hospitals 1997 vs. 2005 SPARC's Data Y1997 = 23,303 vs. Y2005 = 25,392 total births
Weight in Kg
<1.0 1.0-1.5 1.5-2.0 2.0-2.5 >2.5
Per
cen
t
0
10
20
30
40
50
60
70
80% All Regional Cases at WMC
% All NICU DRG's in Region Y1997 = 3129 - 13.4%
Y2005 = 3685 - 14.5%Y1997 = 105Y2005 = 109
Y1997 = 227Y2005 = 160
Y1997 = 371Y2005 = 369
Y1997 = 391Y2005 = 516
Y1997 = 2035Y2005 = 2531
Y1997 = 8.7%Y2005 = 10.0% of all BirthsPrimarily:MalformationsSepsis/PPHNMeconium AspLate Preterm
RepresentsY1997 = 0.45%Y2005 = 0.43%of all Births
70% of All Preterm Births Are Late Preterm (34-36 weeks gestation)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.pdfKalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007Kalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007
Late Preterm’s
< 32 wks
32-33 wks
34 – 36 Weeks
Late Preterm Neonates Consume Large QuantitiesLate Preterm Neonates Consume Large Quantities of Aftercare and Need Follow-up Interventionsof Aftercare and Need Follow-up Interventions
Percent Preterm in USA
Y2004
AcknowledgementsAcknowledgementsRegional Perinatal Center
Edmund La Gamma, MDHeather Brumberg, MD
Susan Marchwinski, RN, MSDonna Dozor, RN, MS
Kathy Rogan, RNClare Nugent, RN
Tania Mangones, MDC. D. Hsu, MD, MPHPaul Visintainer PhD
Perinatal NetworksCheryl Hunter-Grant, LMSWMarilyn Serbetzian, RN, NPAnnette Lopez-Kendra, RN
Caren Fairweather, MPSStephanie Sosnowski, ICCE
March of Dimes Perinatal Data CenterJoann Petrini, PhD, MPH
Tomoko Kushnir
Regional Perinatal Forum Steering Committee for their ongoing time, effort Regional Perinatal Forum Steering Committee for their ongoing time, effort and dedication to developing our regional perinatal health initiativeand dedication to developing our regional perinatal health initiative
ThankThank You !You !
Percentage Change in Birth Weight in USA 1990 vs. 2004Percentage Change in Birth Weight in USA 1990 vs. 2004
More Preterm
Fewer Post-Term
Communicating With and Educating ConsumersCommunicating With and Educating ConsumersLower Hudson Valley Perinatal NetworkLower Hudson Valley Perinatal Network
Westchester44%
Rockland15%
Putnam4%
Dutchess11%
Ulster6%
Sullivan3%
Orange17%
% Birth by County% Birth by County
(n = 29,932 annual births)(n = 29,932 annual births)Previously
Just 26%
Births had
Access to
Perinatal
Networks
New York Vital Statistics 2003
NewlyFunded Perinatal NetworkY2006
*Total discharged home excludes inhouse transfers
Source: SPDS- NICU Module 2006
The Value of CooperativenessThe Value of Cooperativeness THE REGIONAL NEONATAL CENTER THE REGIONAL NEONATAL CENTER
ADMISSIONS 1989-1999ADMISSIONS 1989-1999
0
100
200
300
400
500
600
700
800
89 90 91 92 93 94 95 96 97 98 99
YEAR OF ADMISSION
< 1000 g 1001-2000 G > 2000 g
Growth ofCommunity Level II & III
Source: 2006 SPDS
What Type of Malformations in NYS ?What Type of Malformations in NYS ?(42,500 births in our catchment area)
Cardiovascular > Genitourinary > Musculoskeletal >> Chromosomal
26% 19% 18% ~3%
VSD Hypospadias Hip Dislocation Trisomy 21 ASD Obstructive Club Foot (66% of all)Valves
General Surgical per ~42,5000 births in Hudson Valley
GI Obstructions 69 cases/yrGastroschisis/Omphalocele 18 cases/yrCongenital Diaphragmatic Hernia 11 cases.yr
Total 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 birth80% are a single lesion
Mortality in Pediatrics
5% perinatal-neonatal (LBW/RDS)25% congenital malformations20% SIDS
Source: EBC Data 2006
Source: 2006 SPDS
Prevalence of Births/Malformations in Prevalence of Births/Malformations in Hudson Valley Hospitals: Y1997 & Y2005 Hudson Valley Hospitals: Y1997 & Y2005
80% of Malformations are a single lesion and 75% are 80% of Malformations are a single lesion and 75% are diagnosed < 3 days postnatal agediagnosed < 3 days postnatal age
Region Births ELBW Malformations* (<1500g; 1.4%) (3.8%)
Hudson Valley Y1997 23,303 332 885 Y2005 25,392 378 965
Westchester 12,866 176 488Orange 4,869 66 185Rockland 4,341 52 165Putnam 1,227 23 47
Trend in Total Number of Live Births in the Hudson Valley 1997-2005
28000
28200
28400
28600
28800
29000
29200
29400
29600
29800
30000
1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Incidence of Chronic Lung Disease in <1000g
0 1 2 3 4
Pe
rce
nta
ge
10
20
30
40
50
60
Vermont Oxford PRE Post
July 1999
Vermont-Oxford 199746% (3970/8672)
22%(13/60)
13%(8/59)
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
BPD Rate isAmong Lowestin Nation
Zia et al Ped Res 51(4): A 2279, 2002
The Impact of Highly Experienced and Skilled Clinicians