ANGELS: Does it Work? - PowerPoint PPT Presentation

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ANGELS: Does it Work?

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Title: AHRQ Author: hallrichardw Last modified by: UAMS Created Date: 10/25/2005 11:42:40 PM Document presentation format: On-screen Show Company: UAMS – PowerPoint PPT presentation

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Title: ANGELS: Does it Work?


1
ANGELS Does it Work?
  • Whit Hall MD

2
ANGELS
  • Education
  • Guidelines
  • Referral
  • Arkansas, a rural state
  • 3 areas with practicing neonatologists
  • Other areas with pediatricians

3
ANGELS Education
  • Monthly teleconference meetings
  • Face to face interaction
  • Two way street
  • AHEC contribution

4
ANGELS Guidelines
  • Buy-in to guidelines
  • Apnea
  • Pain
  • Hyperbilirubinemia, etc
  • Published in AMJ
  • Contribution of practicing physicians (e.g.,
    recommendation on apnea)
  • Evidenced based

5
ANGELS Regionalization
  • Better communication
  • Town gown gap narrowed
  • More appropriate (not necessarily more) referrals
  • Is it a good thing for the preterm neonate??

6
Regionalization History
  • Improved outcomes in Wisconsin (Graven, 1977)
  • Improved outcomes in Canada (Sankaran K, 2002)
  • Improved rates of IVH Canada (Synnes a, 2002)
  • Improved outcomes in AR (Kirby, 1995, Palmer,
    Hall RW, 2005)

7
Maternal referral
  • Numerous articles attesting to that
  • Improved outcomes in IVH in California (Towers C,
    2000) and Kansas (Hall Robert, 2003)
  • Improved mortality outcomes in perinatal Canadian
    centers compared to free standing childrens
    hospitals (Shah P, 2005)
  • Decreased disability (Victorian Study Group,
    1991)
  • Decreased mortality (Kollee, 1999 Warner, 2004
    Lubchenco, 1989 Yeast, 1998 Cooper,
    1999Obladen, 1994 Johansson, 2004 Gerlinde,
    2005)

8
But.
  • Higher mortality at night in inborn units
  • Better (40!) if in-house fellow or attending
    (Lee, SK, 2003)
  • Observed mortality less in hospitals without
    residency programs and less volume (104 vs. 62)
    (Horbar JD, 1997)
  • Outborn status protective in US Centers (NEOPAIN
    trial, Rao R, Hall RW, 2006)
  • No difference in mortality after adjusting for
    prenatal steroids (NEOPAIN trial, Palmer KG, Hall
    RW, 2005)
  • NEOPAIN trial required transfer within 7 hours

9
Problems with Maternal Transport in Arkansas
  • Rural state with long distances to travel in
    preterm labor
  • Home for threatened preterm labor not well
    developed
  • Evolving transport system with established
    neonatal transport system
  • Hospital competition
  • Money, pride, prestige

10
Summation of literature
  • Overwhelming support for regionalization
  • Overwhelming support for maternal transport
  • IVH always decreased in inborn population
  • Selection bias a problem in all studies
  • Refer patients who are survivable
  • Outborn babies may require emergency delivery
  • Abruption, Uterine rupture, prolapsed cord, etc

11
ANGELS Referral
  • Regionalization works
  • A neonatologist does not an intensive care
    nursery make
  • Hindrances to regionalization
  • Money
  • Prestige
  • Why UAMS???

Palmer, Hall, et al, 2005 Fanaroff Martin, 7th
ed, 2002
12
Why We Started Mortality Data from 1995-2000
ACH p0.039 for 500-600gms VtOx plt0.001 for
500-600gms NICHD plt0.001 for 500-600gms
ACH p0.087 for 600-700 gms VtOx p0.02 for
600-700gms NICHD plt0.005 for 600-700gms
13
Why We Started Mortality Data From 1995-2000
ACH p0.0135 for 500-750
VtOx plt0.0001 for 500-750
NICHD plt0.0001 for 500-750
Vt Ox p0.0065 for 750-1000 NICHD p0.026 for
750-1000
14
Why We Started IVH Data From 1995-2000
500-750 750-1000 1000-1250
1250-1500 ACH p0.047 p0.33 p0.002
p0.02 NICHD plt.0001 p.0004 p.0261 p.10
15
Evidence
  • Better outcomes with inborn delivery in AR
  • Need for education
  • Medicaid deliveries
  • Large impact (55 coverage)
  • Easy to work with
  • Centralized

16
Survival 2001-2004


plt0.05 plt0.01
17
Survival 2001-2004
plt0.05 plt0.01




18
Survival 2001-2004
plt0.01





19
Survival 2001-2004
plt0.01 UAMS vs. all others
20
Survival 2001-2004
Plt0.01 at all weights
21
Grade 3 and 4 IVH Rate
plt0.05 plt0.01




22
Why the Improved Outcomes at UAMS
  • Maternal Transport
  • Strong OB/Perinatal program
  • ACH backup
  • Nursing experience
  • UAMS administration backup
  • In house neonatal coverage
  • Medicaid

23
Number of UAMS VLBW Admissions
ANGELS
24
What We Know
  • UAMS has better survival in VLBW neonates
  • Less IVH in the inborn population
  • ANGELS has increased inborn delivery
  • Back-up of ACH
  • Medicaid is in a good position to advocate for
    better outcomes regardless of pride and prestige

25
What We Must Research
  • Cost
  • Initial hospital
  • Long term
  • Long term outcome and satisfaction of families
  • Quality of survival

26
Conclusion
  • ANGELS is building a better medical system
  • IVH rates are markedly improved survival is
    modestly affected in the system
  • More research is needed on long term outcomes and
    costs
  • ANGELS/Medicaid is a smart, cost effective system
    who cares for her clients, especially compared to
    other programs (FEMA)
  • Funding should remain intact for AHRQ, Medicaid,
    and ANGELS
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