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Edmund F. La Gamma, M.D. Chief, Division of Newborn Medicine Director, Neonatal-Perinatal Fellowship Program

Toward Achieving “ Better” Practices Regional Forums & Data Analysis. Edmund F. La Gamma, M.D. Chief, Division of Newborn Medicine Director, Neonatal-Perinatal Fellowship Program Professor of Pediatrics, Biochemistry & Molecular Biology. Long Term Impact! 12% of VLBW’ Will have

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Edmund F. La Gamma, M.D. Chief, Division of Newborn Medicine Director, Neonatal-Perinatal Fellowship Program

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  1. Toward Achieving “Better” Practices Regional Forums & Data Analysis Edmund F. La Gamma, M.D. Chief, Division of Newborn Medicine Director, Neonatal-Perinatal Fellowship Program Professor of Pediatrics, Biochemistry & Molecular Biology

  2. Long Term Impact! 12% of VLBW’ Will have Cerebral Palsy With a Prorated Lifetime Cost of $1 million/pt 8% of All Births Utilize 46% of Neonatal Health Care Dollars 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 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 Economic Impact of Perinatal Health Care United States - Y2001

  3. What is the Core Problem In “Public” Health Care

  4. Quality of Care Value = Cost of Service Calculating the “Value” of Medical Services

  5. * 100%’ile 50%’ile Effort or Cost or People Required to Accomplish Goal The Cost of the “Highest” Quality of Care *** The “Zagat Survey” of Health Care *** Hospital B Hospital A * If no significant factual difference - “B” is at risk of bankruptcy ! ?

  6. What’s Really on Everyone’s Mind

  7. Do We Truly Know What Rx Is Best ?

  8. Don’t We Risk Making the Whole Health Care System One Large Public Health Experiment And then… Losing The Trust of Our Patients as Individuals ?

  9. Can we do better?

  10. The New Perinatal Health Code System – Y2005 DOH Stakeholders RPC MFCH RPC PN Medical QA RPF Hospitals SPDS Data collection Health Dept SW Co-Chair RPC PN Co - Chair NE Insurers NW SE Steering Committee PCAP MOMS March of Dimes Report card/ Benchmarking Transport Access to care Birth outcomes Breastfeeding Pt Education Quality of Care Best practices Education WIC Outcomes Lactation Others

  11. Regionalization Enables Novel Services That Can’t Be Replicated Everywhere “Economies of scale – develop & maintain all 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 for Rare problems

  12. How does the Lower Hudson Valley Look ?

  13. Population Growth in New York State Population New York State Y2000 18,998,700 Y2004 19,227,100 Hudson Valley * Y2000 2,185,700 Y2004 2,258,300 Up 1.2 % Up 3.3 % • *The Hudson Valley ranks first among the ten regions in NYS for population growth.

  14. What are the Birth Demographicsfor the Hudson Valley ? Down 10% All NYS Births 278,000 Y1997 249,947 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 Up 9% Up 14%

  15. Where are the Births ? % Birth by County (n = 29,932 annual births) New York Vital Statistics 2003

  16. Is Regionalization Having an Impact in the Hudson Valley? Source: EBC Data 2006

  17. Concentrating Rare Problems Requiring Large Efforts in One Place • Very Low Birth Weight ~1 % • ( ~3 lbs or 1500g or < 32 wks) • Extreme Prematurity < 0.5 % • ( < 2 lbs or < 1000g or < 28 wks)

  18. Source: SPDS- NICU Module 2004- 2006 Evidence for Impact of Regionalized Services Last Three Years of Change 3 2 1

  19. 3.4% of all births in NYS (9,452/yr) Hudson Valley Y1997 885 Y2005 965 80% of Malformations are a single lesion 75% of Malformations are diagnosed < 3 days postnatal age Incidence of Malformations

  20. Utilization of Specialized Services Over Time Represents Y1997 = 0.45% Y2005 = 0.43% of all Births Y1997 = 8.7% Y2005 = 10.0% of all Births Primarily: Malformations Sepsis/PPHN Meconium Asp Late Preterm

  21. < 32 wks 32-33 wks Late Preterm’s 34 – 36 Weeks Late Preterm Neonates Consume Large Quantities of Aftercare and Need Follow-up Interventions 70% of All Preterm Births Are Late Preterm (34-36 weeks gestation) Y2004 Percent Preterm in USA www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdf Kalia JL, Visintainer P, Kase J & Brumberg HL, PAS, Toronto, #8075.8, 2007

  22. Regional Perinatal Center Edmund La Gamma, MD Heather Brumberg, MD Susan Marchwinski, RN, MS Donna Dozor, RN, MS Kathy Rogan, RN Clare Nugent, RN Tania Mangones, MD C. D. Hsu, MD, MPH Paul Visintainer PhD Acknowledgements Perinatal Networks Cheryl Hunter-Grant, LMSW Marilyn Serbetzian, RN, NP Annette Lopez-Kendra, RN Caren Fairweather, MPS Stephanie Sosnowski, ICCE March of Dimes Perinatal Data Center Joann Petrini, PhD, MPH Tomoko Kushnir Regional Perinatal Forum Steering Committee for their ongoing time, effort and dedication to developing our regional perinatal health initiative

  23. Thank You !

  24. Percentage Change in Birth Weight in USA 1990 vs. 2004 Fewer Post-Term More Preterm

  25. Communicating With and Educating ConsumersLower Hudson Valley Perinatal Network % Birth by County (n = 29,932 annual births) Previously Just 26% Births had Access to Perinatal Networks Newly Funded Perinatal Network Y2006 New York Vital Statistics 2003

  26. *Total discharged home excludes inhouse transfers Source: SPDS- NICU Module 2006

  27. The Value of CooperativenessTHE REGIONAL NEONATAL CENTER ADMISSIONS 1989-1999 Growth of Community Level II & III

  28. Source: 2006 SPDS

  29. 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/yr Gastroschisis/Omphalocele 18 cases/yr Congenital Diaphragmatic Hernia 11 cases.yr Total 98 case/yr

  30. 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 birth 80% are a single lesion Mortality in Pediatrics 5% perinatal-neonatal (LBW/RDS) 25% congenital malformations 20% SIDS

  31. Source: EBC Data 2006

  32. Source: 2006 SPDS

  33. Prevalence of Births/Malformations in Hudson Valley Hospitals: Y1997 & Y2005 RegionBirthsELBWMalformations* (<1500g; 1.4%) (3.8%) Hudson Valley Y1997 23,303 332 885 Y2005 25,392 378 965 Westchester 12,866 176 488 Orange 4,869 66 185 Rockland 4,341 52 165 Putnam 1,227 23 47 80% of Malformations are a single lesion and 75% are diagnosed < 3 days postnatal age

  34. The Impact of Highly Experienced and Skilled Clinicians Vermont-Oxford 1997 46% (3970/8672) BPD Rate is Among Lowest in Nation 22%(13/60) 13%(8/59) Post Vermont Oxford PRE July 1999 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 Zia et al Ped Res 51(4): A 2279, 2002

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