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Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health

A Closer Look at Prematurity and Infant Death: Variation in Receipt of Antenatal Corticosteroids, Massachusetts 2004-2008. Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health June 6, 2012. 1. Prematurity. Preterm: < 37 weeks gestation

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Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health

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  1. A Closer Look at Prematurity and Infant Death: Variation in Receipt of Antenatal Corticosteroids, Massachusetts 2004-2008 Lizzie Harvey, MPH CDC/CSTE Applied Epidemiology Fellow Massachusetts Department of Public Health June 6, 2012 1

  2. Prematurity • Preterm: < 37 weeks gestation • US: 1 in 8 births are premature • $26 billion/year

  3. Consequences of Prematurity • Chronic problems • Intellectual disabilities • Cerebral palsy • Breathing and respiratory problems • Vision and hearing loss • Feeding and digestive problems • Prematurity is one of the leading causes of infant death

  4. Burden of Prematurity, US 2005-06

  5. Burden of Prematurity, MA 2008 68.8% of MA infant deaths were due to conditions originating in the perinatal period

  6. Causes of Preterm Infant Death • The primary cause of preterm infant death is respiratory distress syndrome (RDS)

  7. RDS is Preventable • Administration of antenatal corticosteroids (ANC) can improve infant outcomes is associated with • Decreased RDS • Decreased intraventricular hemorrhage • Decreased mortality

  8. ACOG Recommendation

  9. Study Question:Are there differences in antenatal corticosteroid (ANC) administration and outcomes among infants in MA who were eligible for treatment?

  10. Methods • Linked birth-infant death data in MA from 2004-2008 in Pregnancy to Early Life Longitudinal (PELL) data system • Eligibility criteria: • 24-34 weeks GA • Level III Hospitals • Frequency distributions and multivariate logistic regression models were used to assess risk controlling for covariates

  11. Methods • Gestational age (GA): combination of clinical estimate (CE) and calculated age based on the last menstrual period (LMP) • Used LMP when the CE was within 2 weeks of LMP • Used CE in all other cases

  12. Methods • Exposure and outcome criteria: • Steroid for Neonatal Pulmonary Maturity: • “Glucocorticoid administered to mother 24-48 hours prior to premature delivery at 28-32 weeks. The administration of the steroid augments the maturation of the fetal respiratory system” • Infant death: • Death < 1 year of age

  13. Results 397,704 Births 171,719 Level III 43.2% 11,895 24-34 wks GA 6.9%

  14. Demographics

  15. Outcomes of Interest 397,704 Births 171,719 Level III 43.2% 11,895 24-34 wks GA 6.9% 1886 Yes ANC 15.9% 10,009 No ANC 84.1% Less than 1 out of every 6 eligible infants received ANC

  16. % ANC administration by year, Level III hospitals, MA 2004-2008 P=0.0039

  17. ANC Variation

  18. Adjusted Odds of Receiving ANC

  19. % ANC Administration by Gestational Age

  20. Distribution of Level III Hospitals

  21. ANC Administration by Hospital, Level III Hospitals, MA ANC Eligible Infants, 2004-2008 P<0.0001

  22. Outcomes of Interest 397,704 Births 171,719 Level III 43.2% 11,895 24-34 wks GA 6.9% 1886 Yes ANC 15.9% 10,009 No ANC 84.1% 1806 Alive 95.8% 80 Dead 4.2% 9624 Alive 96.15% 385 Dead 3.2%

  23. Variation in Infant Deathamong ANC Recipients N/A=<5 infant deaths in category

  24. Odds of Death among ANC Recipients

  25. % Infant Deaths by Gestational Age among ANC Recipients

  26. Outcomes of Interest 397,704 Births 171,719 Level III 43.2% 11,895 24-34 wks GA 6.9% 1886 Yes ANC 15.9% 10,009 No ANC 84.1% 1806 Alive 95.8% 80 Dead 4.2% 9624 Alive 96.8% 385 Dead 3.2%

  27. No difference between preterm-related causes of death by ANC receipt in infant deathsp=0.93 Differences in Cause of Death

  28. Congenital malformations more prevalent in non-ANC infant cause of death p=0.008 Differences in Congenital Malformations

  29. More infants who did NOT received ANC died within the first 24 hours of lifep=0.0043 Differences in Time of Death

  30. % Infant Deaths by Gestation and ANC Receipt

  31. ANC Administration and Infant Deaths by Hospital Notes: Hospital 1 had no recorded ANC administration data and therefore no ANC infant death data Hospitals 3 and 4: ANC infant death data suppressed due to <5 deaths Between variation: ANC Admin p=<0.0001; ANCinfant death p=0.0038; No ANC infant death p=0.023 Within variation: Only 2 hospitals had significant differences between the two death categories (Hospital #2 : p=0.0043; Hospital #6: p=0.028)

  32. Limitations • Administrative data • No ICD-9 code association with ANC receipt • Differences in BC guidelines and ACOG recommendations • Discrepancy with medical records: • 2008 (22-<30 weeks GA or <=1500g): 83.9% • Comparable data: 23.5%

  33. Conclusions • Higher rates of steroid use among lower gestational ages • Higher rates of early death among infants not receiving steroids • Possible trend that hospitals with lower steroid rates have higher mortality rates

  34. Next Steps • Examine data quality • Chart review with 1 hospital • 1 year of data • Compare BC steroid status to hospital records • Scenario 1: Data quality is poor • Definition on BC • Educate hospital registrars • Scenario 2: Data is reliable • Dig deeper into sources of variations

  35. Acknowledgements • Hafsatou Diop, MD, MPH • Xiaohui Cui, PhD • Milton Kotelchuck, PhD, MPH • Munish Gupta, MD, MPH • Angela Nannini, PhD • Maria Vu, MPH • Emily Lu, MPH • Karin Downs, RN, MPH • CDC/CSTE Fellowship

  36. References • CDC Premature Birth: • http://www.cdc.gov/Features/PrematureBirth/ • IOM Report: • National Research Council. Preterm Birth: Causes, Consequences, and Prevention. Washington, DC: The National Academies Press, 2007. • ACOG recommendations: • http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co475.pdf?dmc=1&ts=20120426T1750113547 • PELL Data System: • https://sph.bu.edu/index.php/Maternal-a-Child-Health/Pregnancy-to-Early-Life-Longitudinal-Linkage-bPELLb/menu-id-452.html • MA Death Statistics: • http://www.mass.gov/eohhs/docs/dph/research-epi/death-report-08.pdf • Preterm-related cause of death ICD classifications: • Mathews TJ, MacDorman MF. Infant mortality statistics from the 2004 period linked birth/infant death data set. National vital statistics reports; vol 55 no 15. Hyattsville, MD: National Center for Health Statistics. 2007. • Antenatal Steroid Organization: • http://daybeforebirth.org/index.html

  37. Thank you Contact Information:Lizzie.Harvey@gmail.comHafsatou.Diop@state.ma.us

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