Improving Perinatal Regionalization for Preterm Deliveries in a Medicaid Covered Population: Initial Impact of the Arkansas ANGELS Intervention

Abstract

Objective. To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice. Data Sources. A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n 5 5,150) were used for analysis. Study Design. Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center. Principal Findings. Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting. Conclusion. Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

Location of childbirth for rural women: implications for maternal levels of care

“…20–24 We replicated this list as closely as possible, using ICD-9 diagnosis and procedure codes, and defined a patient as high-risk if the discharge record for her childbirth hospitalization contained a diagnosis for a condition for which MFM consultation or referral was recommended.…”

“…13 Traveling greater distances for obstetric care may put women and infants at increased risk for morbidity, but such a decision may be advisable when clinical conditions warrant services that are not available locally. 9,20,34 Additionally, prior research indicating greater risk of maternal morbidity (such as postpartum hemorrhage) and postpartum complications in low-volume rural settings may influence clinical recommendations or personal decisions regarding delivery location. 35–37 Indeed, our findings show higher rates of non-local childbirth among rural women whose local hospital has 460 births or fewer each year (Table 3).…”

The associations of parental under-education and unemployment on the risk of preterm birth: 2003 Korean National Birth Registration database

“…Evidence indicates that preterm infants are more likely to survive if they are born in hospitals with neonatology expertise, neonatal intensive care unit capacity (Phibbs et al 2007;Phibbs et al 1996;Warner et al 2004), and higher patient volumes, and that transport of a preterm infant after delivery is not an effective substitute for delivery in such a setting (Lasswell et al 2010). So improving perinatal regionalization for preterm deliveries in socioeconomically deprived population is also important (Bronstein et al 2011). Given that this was an observational study using the NBR database, there were some specific limitations. Firstly, there were some inevitable difficulties associated with using this type of database.…”

Annual volume of very low-birth-weight infant deliveries appears to be more important than level of neonatal intensive care unit for optimising perinatal care

“…This may cause a serious unbalance in the investment of financial and human health resources, whereas existing mid-level primary care centres may result in similar outcomes for VLBW 2. Potential of upgrading services, including employing telemedical consultations3 regularly, should be assessed for optimising capabilities of these lower level perinatal services.…”