MCHB/EPI Miami Conference — December 7 - 9, 2005

Toward Improving the Outcome of Pregnancy — Transcript

GEORGE LITTLE: Well, this is exciting being here. First time to this meeting. There are people whose work I've read and mentors of mine who I've seen around but perhaps the more exciting things is to wander through the posters and to see some of the subject matter that's being covered. Lilian and I were commenting about that that it's just has been refreshing. We're going to cover territory fairly fast because Wanda's quite a taskmaster. We've had our organizing telephone calls and she's told me she has a big hook up here. My job was perhaps to start off and mention a little bit about the history of regionalization and how things started and then to look a little bit at where I spend most of my time and that is in neonatal parinatal medicine neonatology as you heard from the introduction.

Something exciting happened this year in that Stan Graven got the APGAR award recently at the Annual American Academy of Pediatrics meeting. Stan Graven started out as a research biochemist in a laboratory and then went to Wisconsin . I see Russell Kirby nodding his head down there and he did something that was seminal. He went out into Wisconsin hospitals and found and documented the variation and hospital practices and outcomes back in the late '60's and that so far as I'm concerned is where most of what we're doing today started. Stan was one of the key people and if you look at what he's done and what he's gone on to and he's still doing his thing and getting the APGAR award this year and everything, he went on to go into public health, became the dean of a school of public health and does all those sort of things and I'm proud to be able to say that he's one of my mentors and he's also a neonatologist. So he started out with this in Wisconsin in the late '60's.

Things didn't get published the way they do today quite as quickly. It finally appeared in press in 1976 but (inaudible) American Academy of Pediatrics and you had people around from ACOG and AAP that led to the movement to produce TIOP One and I can remember when TIOP One was in the works for about three or four years. I went to the shores of Sunny Lake Winnebago in Osh Kosh with some of the meetings that were there and this was a direct outcome of work from Stan Graven and Joe Butterfield and people such as that and many in the nursing sector and public health sector and so forth and TIOP One finally published and came out as a monograph supported by the March of Dimes in 1976 and to me the zingers from TIOP One--I was just a couple of years into my first job as a neonatologist at the time. My first and only real job at Dartmouth , I guess, I stayed there all this time. One of these days I'll move on perhaps--emphasized needs assessment and resource allocation. That's the zinger to me of what we're trying to do is analyzing what are the needs in (inaudible) parinatal (inaudible) and how are we going to allocate the resources, the levels and so forth we're going to hear more about today.

Universal risk assessment is an important part of that and the organization of hospital based services, the so called levels of care appeared in TIOP One and then down at the bottom of the slide what you see is the section in the back of TIOP One for those of you who have a copy. What needed to be done to move on into the future and that included financing because at that time there wasn't any financing to get parinatal healthcare organized and off the ground. There's a big section on that including what it costs to have a budget to run a unit and that included some evaluation and professional education and so forth and then a section on initiating action.

In the 1980's as you heard Wanda mention and I was involved with this at the time the college and the academy continued their involvement along with the nursing profession, the March of Dimes, family practice group and so forth into pushing this issue and pushing and pushing. Part of the pushing was to get the college and the academy together to publish a single document instead of the old standards for neonatal care into separate obstetrical standards into a single guidelines for parinatal care. This is the well worn beat up marked up cover of my copy and it appeared in 1983 and subsequently has been through multiple editions and I will argue that guidelines in the college and the academy had been consistent in their support of regionalization and what's gone on. I will also admit and say in the question and answer series if you want to get to it it's gotten watered down for various reasons and I think as you look through the guideline editions over the years that it's been out, the 20 plus years they've been out they've got consistently less specific in terms of their recommendations and one of the questions on the table is why and what do you do about that.

TIOP Two was, sort of, hatched for a while. I think the first meeting that I went to saying we got to do something about the fact that it looks like the regional care system in the country is beginning to come apart was in Washington in about 1986 and 1987 and it took a number of years to get things going and then the March of Dimes stepped up to bat again as they always do and said, "Okay, let's get going. We will reconstitute the committee on parinatal health and TIOP Two or TIOP Two or whatever you want to call it," the '90's and beyond came out as you can see from the embargo notice on this copy in 1993 and what was that a response to? Well, you can argue at what it was a response to and I'm sure everybody in the room has an opinion. To me it was, kind of, this funny feeling we had that we weren't doing as well as we could or should do and that the structure of the system was beginning to come apart for one reason or another. Did TIOP Two answer that? I don't know. We can talk about that. I know that at the time I was so heavily involved in it we sure as heck tried but whether we did as well as we could have or whether we got all the issues as well as we could or should have is an issue.

TIOP Two definitely broadened the focus. We argued about this in the committee meeting. We had town meetings across the country and the focus very specifically was changed from TIOP One which was largely a third trimester hospital based focus to preconception care, even perhaps interconception care but certainly preconception care through to and including follow up is present in TIOP Two of 1993 and there certainly was a broadened emphasis on out patient care and you can define that in different ways if you want to but I'll get back to that in a few minutes.

TIOP Two had a special section and tried to move heavily into the issue of data evaluation and accountability. Computer science was coming in. We're beginning to be able to develop databases that didn't take vital statistics. In four or five years we could put them on our desktops and you could see that at work in the debates of the committee on parinatal health, the second one that was there in the '90's. Evaluation was certainly there.

One of my issues and Kay Johnson who has worked with me on this over years and so forth knows that I have a special feeling about accountability. I think somehow one of the issues and I like to put it on the table is that accountability has never really come out the way that it could or should and I think there are some reasons for that but I'll lay that out there for discussion later on. Important to this and I'll come back and reinforce this in a few minutes is that TIOP Two said that the existing system of care with risk assessment and the levels of care needed to be reconfirmed and was reconfirmed in the document. There was a lot of pressure to create a level four plus and you always get in this fragmentational levels but to me the basic concept of three levels of care has made a lot of common sense and I think is still the foundation of much of what we do although expressed in different ways.

One issue that has to be addressed and which I think I have to put on the table is it better care or better babies? And where do we stand with respect to that issue today and how does that affect the debate about regionalization? Doug Richardson who many of you know was in Boston passed away tragically had a paper in pediatrics in 1998 trying to look at this issue from some work that he and a group were doing and a (inaudible) is made there that they thought there was about a 50 percent decrease of less than 1,500 gram mortality in a study that involved two cohorts in the time frames mentioned and that about a third of the decline was attributed to improved condition on admission. IE, better babies and those of use who are card-carrying neonatologists couldn't take the credit for that third. We applied what we knew but in fact in that period of time we were getting better babies in the '70's, '80's and '90's but that about two-thirds of the decline was attributed to (inaudible) care. What was the big (inaudible) care thing that happened at about the time that Doug was doing his paper (inaudible) right? I mean, if you look at the literature and you see what happened it's in this interim that (inaudible) was applied and certainly that was one of the biggest if not the biggest technological knowledge thing that came along.

Bill Silverman passed away this year. Bill Silverman started out in neonatology back in the '50's and '60's and for those of you who knew the literature and knew Bill a little bit you knew that he was more than a gadfly. He had this long, long list of people including me that he bugged the hell out of with emails. "George, when you going to speak up about this, that or the other thing." And Bill was a great one for sending little zingers into various places besides writing (inaudible) monographs on things and based out of (inaudible) for a while and the (inaudible) please so forth and so on. The little zinger from Bill appeared in 1993 "Is neonatal medicine in the United States out of step?" And I think we have to keep this issue on the table because (inaudible) neonatologist also push us a little bit during the Q and A thing. I mean, I think there are some aspects of what neonatologists do and so forth that we need to think about a little bit. Neonatal care in thinking about it has been responsible for much of the income and parinatal outcomes. I think that Doug Richardson's paper was an attempt to document that.

I think there are some other evidence of that and we can talk about that but I also have to say that it may be that neonatology and what occurs after the delivery of the baby is not going to be able to--in fact, I'll just say we're not going to be able to contribute the disproportionate contribution we have been able to make to future outcome improvement. Now, that's looking at it from a mortality basis. The issue of morbidity and what we can do as neonatologists and with the neonatal part of the spectrum I think there's a lot that can be accomplished there and will be accomplished and we can talk about that a little bit later.

One thing that I'd like to spend a couple of minutes on because it gets into the issues that Bill Silverman brought up and which I've had the opportunity to work with a team at Dartmouth on is how many neonatologists are there? I mean, I've got on my certificate it's, like, number 389 or something or other. I don't know what Lilian's is but, you know, we're the great (inaudible) people that (inaudible) there, like, 4,000 or 5,000 of us now and Lilian may be able to talk about that. Do we have adequate capacity? Are we doing the right thing? Dave Goodman and some people at Dartmouth decided to look at this and we're going to run through just a couple of issue with regard to neonatal care capacity for minute. This paper appeared in 2001. Neonatal intensive care resources located according to needs. Regional variation and neonatologists beds and low birth weight babies. What Dave did and the rest of us with the group was to split up the United States . If you look at things with regard to where low birth weight babies get their care and go through some statistical modeling and so forth you can come up with 246 knickers or neonatal intensive care regions and this is just the state of Ohio split up on this basis for where babies go to get their neonatal intensive care. And neonatal care capacity using this cross sexual analysis of the 246 knickers (inaudible) association between the capacity, neonatologists and hospital beds and low birth weight and very low birth weight comes up with the observation that looking at it by quintiles that neonatal care capacity and need has something that I suspect that you're not surprised at that regional variation is not explained by need as expressed by low birth weight and you've got the distribution here by quintiles of the number of births per neon. Neon is a neonatologist, also the name of a dog in our unit and 169 births per bed to the low quintile which has a higher number and the thing here is that there's a variation across 246 knickers in the United States that's more than four-fold.

Moving on a bit then to neonatal intensive care capacity and neonatal mortality, the same group publishing in the New England Journal in 2002 looked at neonatal care capacity and outcomes took a years birth cohort in the United States risk adjusted it for maternal and neonatal factors and came up with something that I think you're probably not too surprised at but it, kind of, hurts for those of us who are neonatologist to see this and what this basically said was, you know, something is better than nothing. Having a George Little or a Lilian Blackmon around you probably end up having better neonatal outcomes than if Lilian and George weren't there. But the problem with it is if you look at it in quintiles, if you go to the second quintile you do a little bit better but then you keep piling on through the third, fourth and fifth quintiles and you don't get any better and that situation apparently, at least from the perspective of mortality and outcomes appears to be present in the United States and not only that there's no consistent relationship that we could come up with between the number of (inaudible) beds and mortality.

So is neonatal intensive care always better? Insights from across national comparison of reproductive care. This probably doesn't surprise you very much at all and Bill Silverman sent me an email saying, "George, you're right on. Thanks a lot. It's about time somebody said that. Print it and send it around (inaudible) place you can go." The United States compared to three other developed countries did not have a consistently better birth weight specific to mortality. It has low birth weight that exceed other countries and it has less extensive preconception and prenatal services and that expends a heck of a lot more in neonatal capacity. Now, to finish up let me just run through a couple of quick issues. One is whether more is worse as we go along.

Some work that Kay Johnson and I did looking at state parinatal QI and what states are actually doing back in the late '90's and we've, sort of, documented the fact that those of you who are responsible for state MCH things aren't doing very well, at least as near as we could make (inaudible). Overall there are some great standout issues but by and large things have slipped. We did a survey of state agencies looking at things and thought there's more opportunities for the state to be better. The state of Ohio I want to mentioned because Ohio is attempting to move its state parinatal MCH things in a direction of dealing with quality improvement at the patient provider level and with performance mo9nitoring and set up state data use committees in a regional basis. They have continued the old model from TIOP One of state parinatal guidelines of six geographic regions and have been attempting to move to a situation where you have parinatal data use consortiums in the six regions going through a PPOR evaluation and Bill Sappenfield and other people have been up to help out with that and develop six data driven regional teams that include providers. They've decided to use Vermont Oxford and I think you're going to hear Vermont Oxford come up a few times in these comments and I'd like to get into the question answer thing if you'd like to. Lilian and I just came from a meeting in Vermont (inaudible). If you don't know what it is you ought to because it's a data system that now has over a quarter of a million low birth weight babies listed in it and we're attempting to guide Ohio to use it to some extent and some other places and the reason why these slides are here are to get Vermont Oxford under the table. It comes out of the neonatology community as a non-profit effort. There are, of course, other data systems that have grown.

The pediatrics with an X data system that's used by the largest sub specialty group practice in the country also is now beginning to present (inaudible) literature publications. This is just to show that Vermont Oxford is involved in quality improvement efforts. California spelled properly and not the wrong way that it's spelled on this slide. I always thought I was a better than average, sort of, proofreader. This disproves that theory. Anyway, California we're going to hear more about. For those of you who know anything about Arizona . Arizona 's got the Arizona Parinatal Trust. Do you know anything about it? Ever heard about the Arizona Parinatal Trust. It's an interesting body that you might want to read about and think about sometime and then we're beginning to move into ways of looking at target populations and I just want to mention this effort by Al Bran and Brian McCarthy and Ann Dunlop that's percolating her way down in Georgia out of the state program originally but using a PPOR analysis and trying to come up with opportunities to intervene with gaps and then in this particular instance to look at repeats with respect to very low birth weight babies.

You're going to hear more in a special session today on preconception care and I put this in to say that preconception care was mentioned in TIOP Two. It was one of the, I think, key points of TIOP Two. I'm going to stop there by referring to something from TIOP Two and I'm not sure that you can see it but way down in the bottom it says something along the line about source wise and wise is the guy sitting on the podium with me. This appears in TIOP Two and I think was the first thing that I saw that tried to pull it together with regard to looking at issues from what I do for the most part which is patient oriented care and the quality improvement focus and the impact of that on birth weight specific mortality and the other interventions that are more (inaudible) public health population basis which looked at birth weight distribution. I'll stop there and look forward to the question session.