ANGELS: Does it Work? Whit Hall MD

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

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

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

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

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

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

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

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

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

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

Why We Started: Mortality Data from ACH p=0.039 for gms VtOx p<0.001 for gms NICHD p<0.001 for gms ACH p=0.087 for gms VtOx p=0.02 for gms NICHD p<0.005 for gms

Why We Started: Mortality Data From ACH p= for VtOx p< for NICHD p< for Vt Ox p= for NICHD p=0.026 for

Why We Started: IVH Data From ACH p=0.047 p=0.33 p=0.002 p=0.02 NICHD p<.0001 p=.0004 p=.0261 p=.10

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

Survival: ** * *p<0.05 ** p<0.01

Survival: ** * * *p<0.05; **p<0.01

Survival: ** * **p<0.01

Survival: p<0.01 UAMS vs. all others

Survival: 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 Maternal Transport Strong OB/Perinatal program Strong OB/Perinatal program ACH backup ACH backup Nursing experience Nursing experience UAMS administration backup UAMS administration backup In house neonatal coverage In house neonatal coverage Medicaid Medicaid

ANGELS Number of UAMS VLBW Admissions

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

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

Conclusion ANGELS is building a better medical system ANGELS is building a better medical system IVH rates are markedly improved; survival is modestly affected in the system IVH rates are markedly improved; survival is modestly affected in the system More research is needed on long term outcomes and costs 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) 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 Funding should remain intact for AHRQ, Medicaid, and ANGELS