ABSTRACT: Very-low-birth-weight (VLBW) neonates (<1500 g) have mortality rates ranging from 15% to 25%; if they survive, major morbidity remains a high risk. Perinatal regionalization can reduce mortality and morbidity through a system of health care for mothers and neonates organized within a geographical area to assess risk, promote resource allocation and appropriate patient transport, and differentiate levels of care to provide the highest quality of care in an economical manner. In 2003, Arkansas established a statewide system for high-risk obstetrics and neonatology by creating an infrastructure for telemedicine (TM) collaboration, consultation and development, and adoption of best practices. This prospective study was undertaken to determine whether TM decreases VLBW deliveries in hospitals without neonatal intensive care units (NICUs), affects morbidity and mortality in these patients, and decreases infant mortality rates.
In 2009, 9 obstetric and nursery sites across Arkansas were designated as TM hospitals because of their high numbers of births. Five of these hospitals did not offer specialized newborn care and were the targeted hospitals. Through a network of established call centers and transport teams, consultations and transports of obstetric and neonatal patients were possible. Mortality and morbidity were assigned to the birth hospitals, which were categorized as TM hospitals–NICU, TM hospitals–non-NICU, non-TM hospitals–NICU, and non-TM hospitals–non-NICU. The main goal was to use TM collaboration to decrease the number of VLBW deliveries at TM hospitals without NICUs. Secondary outcomes included evaluation of changes in morbidity. Comparisons were made for delivery site of VLBW neonates, mortality and morbidity across hospital groups, and before and after TM.
During the 9-month post-TM period, 60 VLBW neonates were delivered in hospitals designated as TM hospitals (with and without a NICU), 202 VLBW neonates in non-TM hospitals (with and without a NICU), and 122 VLBW neonates at the University of Arkansas for Medical Sciences facility. Deliveries of VLBW neonates in TM hospitals–non-NICU decreased from 50 to 27 neonates (13.1%–7.0%, P = 0.0099). The percentage of VLBW deliveries in the remaining hospitals did not change significantly.
During this short study period, a decrease in mortality was noted in the TM–non-NICU hospitals. Infant mortality statewide decreased during the study period as well. Morbidity, including bronchopulmonary dysplasia, necrotizing enterocolitis, and grades 3 and 4 intraventricular hemorrhage, was unchanged in the TM–non-NICU hospitals in the post-TM period, except that the incidence of intraventricular hemorrhage was slightly increased (P = 0.03).
This is the first study assessing the effects of a TM collaborative program on improving regionalization of perinatal care. Delivery patterns were positively affected in TM–non-NICU hospitals, whereas delivery patterns did not change in non-TM–non-NICU hospitals. These results lend credence to the hypothesis that TM collaboration may decrease the number of VLBW neonates delivered in non-NICU hospitals and support efforts to enhance appropriate regionalization to decrease infant mortality. Further study is necessary to determine whether the gains in regionalization of NICU care and reductions in mortality can be sustained through continued TM collaboration.
Department of Pediatrics/Neonatology, College of Medicine, Arkansas Children’s Hospital; Department of Obstetrics and Gynecology, Center for Distance Health, College of Medicine; and Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR