Edmund F. La Gamma, M.D.Edmund F. La Gamma, M.D.Chief, Division of Newborn Medicine Chief, Division of Newborn Medicine

Director, Neonatal-Perinatal Fellowship Program Director, Neonatal-Perinatal Fellowship Program Professor of Pediatrics, Biochemistry & Molecular BiologyProfessor of Pediatrics, Biochemistry & Molecular Biology

Toward Achieving “Toward Achieving “Better”Better” Practices Practices Regional Forums & Data AnalysisRegional Forums & Data Analysis

Economic Impact of Perinatal Health CareEconomic Impact of Perinatal Health CareUnited States - Y2001United States - Y2001

Excludes stays with charges greater than $1 million.

Source: Agency for Healthcare Research and Quality, 2001 Nationwide Inpatient Sample

Prepared by March of Dimes Perinatal Data Center, 2003

Prematurity/LBW 384,000 $13,593,724,000 All Other 4,227,000 $15,699,376,000 Total 4,611,000 $29,293,100,000

46%

92%

54%

8%0%

20%

40%

60%

80%

100%

Discharges Total Charges

Prematurity/LBW All Other

8% of All Births Utilize 46% of Neonatal Health Care Dollars

Long Term Impact!12% of VLBW’Will have Cerebral PalsyWith a Prorated Lifetime Cost of $1 million/pt

What is the Core What is the Core

Problem In Problem In

““Public” Public” Health CareHealth Care

Calculating the “Value” of Medical ServicesCalculating the “Value” of Medical Services

Quality of CareValue =

Cost of Service

The Cost of the “Highest” Quality of Care*** The “Zagat Survey” of Health Care ***

100%’ile

50%’ile

Effort or Cost or People Required to Accomplish Goal

*

* If no significant factual difference - “B” is at risk of bankruptcy ! ?

Hospital BHospital A

What’s Really on Everyone’s MindWhat’s Really on Everyone’s Mind

Do We TrulyKnow What RxIs Best ?

Don’t We Risk Making the Whole Health CareSystem One Large Public Health ExperimentAnd then…

Losing The Trust of Our Patients as Individuals ?

Can we do better?

DOH

RPCMFCH

Medical QA

SPDSData collection

RPF

NENW SE

SWCo-Chair

RPC PN

Co - Chair

Health Dept

Hospitals

PN

Steering Committee

RPC

Insurers

March ofDimes

Lactation

WIC

PCAP MOMS

Quality of CareBest practices

Education

Stakeholders

Report card/Benchmarking

Transport

Access to careBirth outcomesBreastfeedingPt Education

OthersOu

tco

mes

The NewThe NewPerinatal Perinatal Health CodeHealth CodeSystem – Y2005System – Y2005

Regionalization Enables Novel Services Regionalization Enables Novel Services That Can’t Be Replicated EverywhereThat Can’t Be Replicated Everywhere

““Economies of scale – develop & maintain Economies of scale – develop & maintain allall options” options”

Ventilation – all forms immediately available-high frequency oscillators-jet ventilation-assist-control conventional ventilation

Cardiovascular-nitric oxide-ECMO program-neonatal heart surgery

CNS-head cooling/asphyxia

Clinician Experience: Competence & Availability forRare problems

How does the How does the Lower Hudson Valley Look ?Lower Hudson Valley Look ?

*The Hudson Valley ranks first among the ten regions in NYS for population growth.

Population

New York State Y2000 18,998,700

Y2004 19,227,100

Hudson Valley * Y2000 2,185,700

Y2004 2,258,300

Up 3.3 %

Up 1.2 %

Population Growth in New York StatePopulation Growth in New York State

What are the Birth DemographicsWhat are the Birth Demographicsfor the Hudson Valley ?for the Hudson Valley ?

All NYS Births 278,000 Y1997249,947 Y2005

Hudson Valley Regional Births 23,303 Y1997 (21 Hospitals) 25,392 Y2005

VLBW/ELBW Neonates in Valley 332 (1.4 %) Y1997 378 (1.5 %) Y2005

Down10%

Up 9%

Up 14%

Where are the Births ? Where are the Births ?

Westchester44%

Rockland15%

Putnam4%

Dutchess11%

Ulster6%

Sullivan3%

Orange17%

% Birth by County% Birth by County

(n = 29,932 annual births)(n = 29,932 annual births)

New York Vital Statistics 2003

Source: EBC Data 2006

Is Regionalization Having an Impact in the Hudson Valley?Is Regionalization Having an Impact in the Hudson Valley?

-Very Low Birth Weight ~1 %( ~3 lbs or 1500g or < 32 wks)

-Extreme Prematurity < 0.5 %( < 2 lbs or < 1000g or < 28 wks)

Concentrating Rare ProblemsConcentrating Rare Problems

Requiring Large Efforts in One Place Requiring Large Efforts in One Place

Source: SPDS- NICU Module 2004- 2006Source: SPDS- NICU Module 2004- 2006

Last ThreeYearsof Change

Evidence for Impact of Regionalized ServicesEvidence for Impact of Regionalized Services

11

22

33

Incidence of MalformationsIncidence of Malformations

3.4% of all births in NYS (9,452/yr)

Hudson ValleyY1997 885Y2005 965

80% of Malformations are a single lesion

75% of Malformations are diagnosed < 3 days postnatal age

Utilization of Specialized Services Over TimeUtilization of Specialized Services Over Time

RPC Hospitals 1997 vs. 2005 SPARC's Data Y1997 = 23,303 vs. Y2005 = 25,392 total births

Weight in Kg

<1.0 1.0-1.5 1.5-2.0 2.0-2.5 >2.5

Per

cen

t

0

10

20

30

40

50

60

70

80% All Regional Cases at WMC

% All NICU DRG's in Region Y1997 = 3129 - 13.4%

Y2005 = 3685 - 14.5%Y1997 = 105Y2005 = 109

Y1997 = 227Y2005 = 160

Y1997 = 371Y2005 = 369

Y1997 = 391Y2005 = 516

Y1997 = 2035Y2005 = 2531

Y1997 = 8.7%Y2005 = 10.0% of all BirthsPrimarily:MalformationsSepsis/PPHNMeconium AspLate Preterm

RepresentsY1997 = 0.45%Y2005 = 0.43%of all Births

70% of All Preterm Births Are Late Preterm (34-36 weeks gestation)70% of All Preterm Births Are Late Preterm (34-36 weeks gestation)

www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdfKalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007Kalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007

Late Preterm’s

< 32 wks

32-33 wks

34 – 36 Weeks

Late Preterm Neonates Consume Large QuantitiesLate Preterm Neonates Consume Large Quantities of Aftercare and Need Follow-up Interventionsof Aftercare and Need Follow-up Interventions

Percent Preterm in USA

Y2004

AcknowledgementsAcknowledgementsRegional Perinatal Center

Edmund La Gamma, MDHeather Brumberg, MD

Susan Marchwinski, RN, MSDonna Dozor, RN, MS

Kathy Rogan, RNClare Nugent, RN

Tania Mangones, MDC. D. Hsu, MD, MPHPaul Visintainer PhD

Perinatal NetworksCheryl Hunter-Grant, LMSWMarilyn Serbetzian, RN, NPAnnette Lopez-Kendra, RN

Caren Fairweather, MPSStephanie Sosnowski, ICCE

March of Dimes Perinatal Data CenterJoann Petrini, PhD, MPH

Tomoko Kushnir

Regional Perinatal Forum Steering Committee for their ongoing time, effort Regional Perinatal Forum Steering Committee for their ongoing time, effort and dedication to developing our regional perinatal health initiativeand dedication to developing our regional perinatal health initiative

ThankThank You !You !

Percentage Change in Birth Weight in USA 1990 vs. 2004Percentage Change in Birth Weight in USA 1990 vs. 2004

More Preterm

Fewer Post-Term

Communicating With and Educating ConsumersCommunicating With and Educating ConsumersLower Hudson Valley Perinatal NetworkLower Hudson Valley Perinatal Network

Westchester44%

Rockland15%

Putnam4%

Dutchess11%

Ulster6%

Sullivan3%

Orange17%

% Birth by County% Birth by County

(n = 29,932 annual births)(n = 29,932 annual births)Previously

Just 26%

Births had

Access to

Perinatal

Networks

New York Vital Statistics 2003

NewlyFunded Perinatal NetworkY2006

*Total discharged home excludes inhouse transfers

Source: SPDS- NICU Module 2006

The Value of CooperativenessThe Value of Cooperativeness THE REGIONAL NEONATAL CENTER THE REGIONAL NEONATAL CENTER

ADMISSIONS 1989-1999ADMISSIONS 1989-1999

0

100

200

300

400

500

600

700

800

89 90 91 92 93 94 95 96 97 98 99

YEAR OF ADMISSION

< 1000 g 1001-2000 G > 2000 g

Growth ofCommunity Level II & III

Source: 2006 SPDS

What Type of Malformations in NYS ?What Type of Malformations in NYS ?(42,500 births in our catchment area)

Cardiovascular > Genitourinary > Musculoskeletal >> Chromosomal

26% 19% 18% ~3%

VSD Hypospadias Hip Dislocation Trisomy 21 ASD Obstructive Club Foot (66% of all)Valves

General Surgical per ~42,5000 births in Hudson Valley

GI Obstructions 69 cases/yrGastroschisis/Omphalocele 18 cases/yrCongenital Diaphragmatic Hernia 11 cases.yr

Total 98 case/yr

Impact of Malformations on Pediatric Health Care

Morbidity due to Malformations

33% of all pediatric in-patient days !25% of all pediatric hospital admissions !75% are defined in the first 3 days after birth80% are a single lesion

Mortality in Pediatrics

5% perinatal-neonatal (LBW/RDS)25% congenital malformations20% SIDS

Source: EBC Data 2006

Source: 2006 SPDS

Prevalence of Births/Malformations in Prevalence of Births/Malformations in Hudson Valley Hospitals: Y1997 & Y2005 Hudson Valley Hospitals: Y1997 & Y2005

80% of Malformations are a single lesion and 75% are 80% of Malformations are a single lesion and 75% are diagnosed < 3 days postnatal agediagnosed < 3 days postnatal age

Region Births ELBW Malformations* (<1500g; 1.4%) (3.8%)

Hudson Valley Y1997 23,303 332 885 Y2005 25,392 378 965

Westchester 12,866 176 488Orange 4,869 66 185Rockland 4,341 52 165Putnam 1,227 23 47

Trend in Total Number of Live Births in the Hudson Valley 1997-2005

28000

28200

28400

28600

28800

29000

29200

29400

29600

29800

30000

1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Incidence of Chronic Lung Disease in <1000g

0 1 2 3 4

Pe

rce

nta

ge

10

20

30

40

50

60

Vermont Oxford PRE Post

July 1999

Vermont-Oxford 199746% (3970/8672)

22%(13/60)

13%(8/59)

Decreased incidence of CLD disease using “Optimal FRC Strategy ” to 13%as compare to Pre-July group(22%) & Vermont-Oxford data(46%).5/15 Pt on HFV developed CLD in Post-July group

BPD Rate isAmong Lowestin Nation

Zia et al Ped Res 51(4): A 2279, 2002

The Impact of Highly Experienced and Skilled Clinicians