BMJ 2015;350:h2524 doi: 10.1136/bmj.h2524 (Published 8 May 2015)
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Research News
RESEARCH NEWS Hospital practice explains variation in outcomes in extremely premature infants, US study finds Michael McCarthy Seattle
Much of the variation seen in outcomes among infants born at 22, 23, or 24 weeks of gestation can be explained by differences in hospitals’ practices on whether to initiate active treatment to save the lives of these extremely premature newborns, concludes a new study in the New England Journal of Medicine.1 The study found that hospitals at which active treatment was more often started had higher rates of risk-adjusted survival, both with and without impairment, than hospitals at which active treatment was less often started.
Currently, active intervention, such as the administration of surfactant therapy, intubation, ventilatory support, resuscitation, and parenteral support, is generally not recommended for infants born before 22 weeks of gestation. But for infants born at or after 22 weeks practice varies from institution to institution, and the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that decisions be individualized on the basis of parental preference and the most recent data on survival and morbidity.
However, the researchers warned that their results indicated that counseling parents on the basis of one hospital’s experience may misrepresent their premature child’s chances of survival and risk of neurodevelopment impairment if that hospital has a low rate of initiating active lifesaving treatment in extremely premature patients. For the study, the researchers looked at the treatment and outcomes of 4987 infants born before 27 weeks of gestation at 24 hospitals. They excluded infants with congenital anomalies.
Infants were considered to have received active treatment if they received surfactant therapy, tracheal intubation, ventilatory support (including continuous positive airway pressure, bag-valve-mask ventilation, or mechanical ventilation), parenteral nutrition, epinephrine, or chest compressions. Of the 4987 infants, 4329 (86.8%) received active treatment. Survival and neurodevelopmental impairment outcomes at 18 and 22 months of corrected age were available for 4704 (94.3%) of the children. The participating hospitals had differing patient demographics, practices, and outcomes, but all were members of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, which conducted the study. The results showed that, overall in the network’s hospitals, active treatment was administered to 22.1% of infants born at 22 weeks of gestation and to 71.8% of those born at 23 weeks For personal use only: See rights and reprints http://www.bmj.com/permissions
and nearly all of the infants born at 24 weeks of gestation or later (97.1% at 24 weeks, 99.6% at 25 weeks, and 99.8% at 26 weeks). Of those who received active treatment, 65.0% survived, 56.1% survived without severe neurodevelopmental impairment, and 40.8% survived without moderate or severe neurodevelopmental impairment. All infants born before 22 weeks died within 12 hours of birth. The rates of active treatment for the more premature infants (those born at 22, 23, or 24 weeks) varied widely among the hospitals: the interquartile ranges for hospital rates of active treatment were 7.7% to 100% among infants born at 22 weeks, 52.5% to 96.5% among infants born at 23 weeks, and 95.2% to 100% among infants born at 24 weeks. Five hospitals provided active treatment to all infants born at 22 through to 26 weeks of gestation. The overall rate of survival of infants born at 22 weeks of gestation was 5.1% (3.4% survived without severe impairment and 2.0% survived without moderate or severe impairment). Among those who received active treatment, however, the overall survival rate was 23.1% (15.4% without severe impairment and 9.0% without moderate or severe impairment). Among infants born at 26 weeks the respective survival rates were 81.4% (75.6% and 58.5%), and rates were similar among those who received active treatment.
Statistical analysis showed that rates of active treatment accounted for 78% of the between-hospital variation in survival and for 75% of the between-hospital variation in survival without severe impairment among children born at 22 or 23 weeks and for 22% and 16%, respectively, among those born at 24 weeks. Rates of active treatment did not account for variation in outcomes among those born at 25 or 26 weeks. The researchers concluded, “Outcome statistics that are derived from populations that include large numbers of infants who did not receive active treatment may seem to support decisions to forgo future treatment, resulting in a ‘self-fulfilling’ prognosis. For transparency and accuracy, it is important to take into account whether the infants included in outcome statistics received active treatment when using those data to counsel families.” 1
Rysavy MA, Li L, Bell EF, et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015;372:1801-11.
Cite this as: BMJ 2015;350:h2524 © BMJ Publishing Group Ltd 2015 Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2524 doi: 10.1136/bmj.h2524 (Published 8 May 2015)
Page 2 of 2
RESEARCH NEWS
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Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Research News
RESEARCH NEWS Hospital practice explains variation in outcomes in extremely premature infants, US study finds Michael McCarthy Seattle
Much of the variation seen in outcomes among infants born at 22, 23, or 24 weeks of gestation can be explained by differences in hospitals’ practices on whether to initiate active treatment to save the lives of these extremely premature newborns, concludes a new study in the New England Journal of Medicine.1 The study found that hospitals at which active treatment was more often started had higher rates of risk-adjusted survival, both with and without impairment, than hospitals at which active treatment was less often started.
Currently, active intervention, such as the administration of surfactant therapy, intubation, ventilatory support, resuscitation, and parenteral support, is generally not recommended for infants born before 22 weeks of gestation. But for infants born at or after 22 weeks practice varies from institution to institution, and the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists recommend that decisions be individualized on the basis of parental preference and the most recent data on survival and morbidity.
However, the researchers warned that their results indicated that counseling parents on the basis of one hospital’s experience may misrepresent their premature child’s chances of survival and risk of neurodevelopment impairment if that hospital has a low rate of initiating active lifesaving treatment in extremely premature patients. For the study, the researchers looked at the treatment and outcomes of 4987 infants born before 27 weeks of gestation at 24 hospitals. They excluded infants with congenital anomalies.
Infants were considered to have received active treatment if they received surfactant therapy, tracheal intubation, ventilatory support (including continuous positive airway pressure, bag-valve-mask ventilation, or mechanical ventilation), parenteral nutrition, epinephrine, or chest compressions. Of the 4987 infants, 4329 (86.8%) received active treatment. Survival and neurodevelopmental impairment outcomes at 18 and 22 months of corrected age were available for 4704 (94.3%) of the children. The participating hospitals had differing patient demographics, practices, and outcomes, but all were members of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, which conducted the study. The results showed that, overall in the network’s hospitals, active treatment was administered to 22.1% of infants born at 22 weeks of gestation and to 71.8% of those born at 23 weeks For personal use only: See rights and reprints http://www.bmj.com/permissions
and nearly all of the infants born at 24 weeks of gestation or later (97.1% at 24 weeks, 99.6% at 25 weeks, and 99.8% at 26 weeks). Of those who received active treatment, 65.0% survived, 56.1% survived without severe neurodevelopmental impairment, and 40.8% survived without moderate or severe neurodevelopmental impairment. All infants born before 22 weeks died within 12 hours of birth. The rates of active treatment for the more premature infants (those born at 22, 23, or 24 weeks) varied widely among the hospitals: the interquartile ranges for hospital rates of active treatment were 7.7% to 100% among infants born at 22 weeks, 52.5% to 96.5% among infants born at 23 weeks, and 95.2% to 100% among infants born at 24 weeks. Five hospitals provided active treatment to all infants born at 22 through to 26 weeks of gestation. The overall rate of survival of infants born at 22 weeks of gestation was 5.1% (3.4% survived without severe impairment and 2.0% survived without moderate or severe impairment). Among those who received active treatment, however, the overall survival rate was 23.1% (15.4% without severe impairment and 9.0% without moderate or severe impairment). Among infants born at 26 weeks the respective survival rates were 81.4% (75.6% and 58.5%), and rates were similar among those who received active treatment.
Statistical analysis showed that rates of active treatment accounted for 78% of the between-hospital variation in survival and for 75% of the between-hospital variation in survival without severe impairment among children born at 22 or 23 weeks and for 22% and 16%, respectively, among those born at 24 weeks. Rates of active treatment did not account for variation in outcomes among those born at 25 or 26 weeks. The researchers concluded, “Outcome statistics that are derived from populations that include large numbers of infants who did not receive active treatment may seem to support decisions to forgo future treatment, resulting in a ‘self-fulfilling’ prognosis. For transparency and accuracy, it is important to take into account whether the infants included in outcome statistics received active treatment when using those data to counsel families.” 1
Rysavy MA, Li L, Bell EF, et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015;372:1801-11.
Cite this as: BMJ 2015;350:h2524 © BMJ Publishing Group Ltd 2015 Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h2524 doi: 10.1136/bmj.h2524 (Published 8 May 2015)
Page 2 of 2
RESEARCH NEWS
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
