Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada’s 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group’s guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, “good” if assessed by the time the patient was 1 month of age, “satisfactory” if by 3 months of age, and “poor” if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%–60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was “good” in 28%, “satisfactory” in 66%, and “poor” in 34%.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.</jats:p></jats:sec>

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients

“…Seventy to ninety percent of these children recover spontaneously, while the remaining 10-30% are left with neurological damage, possibly resulting in functional impairments (Chauhan et al, 2014;Evans-Jones et al, 2003;Lagerkvist et al, 2010;Waters, 1999). Children with severe NBPP in, for example, Canada, Sweden, and the Netherlands are usually referred to a tertiary NBPP expert center for further diagnostics and follow-up (Coroneos et al, 2015a;Pondaag et al, 2004;Strombeck et al, 2000). If these children do not show sufficient spontaneous recovery around the age of three months, primary, nerve, surgery may be indicated (Pondaag and Malessy, 2014;Tse et al, 2015).…”

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia

“…Thus, our findings may not be applicable to cohorts that are not followed in such a prescribed manner. 27 The categorization of the two exposures may seem arbitrary, though it was based on prior publications 17,24 and small sample size. Lastly, the duration of shoulder dystocia should be considered as an estimate for we do not have evidence that when measured it was done consistently and accurately.…”

Birth brachial plexus palsy: a race against time

“…Coroneos et al 14 assessed the time of referral of a case of BBPP to a multidisciplinary centre and found that the majority (55–60%) of patients with BBPP identified at birth were not referred for multidisciplinary care. They classified the referred patients on the basis of the month in which referrals were done into first month (good), third month (satisfactory) and beyond 3 months (poor) referral and found ‘good’ in 28%, ‘satisfactory’ in 66%, and ‘poor’ in 34% of the patient referrals.…”