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Regionalization of Care for Preterm Babies in Arkansas: A Review of ANGELS Program

This review explores the impact of the ANGELS program in Arkansas on the regionalization of care for preterm babies. Topics covered include education, guidelines, referral practices, outcomes, and the role of maternal transport in improving neonatal outcomes. The review delves into the literature supporting regionalization, challenges faced, and the need for further research on long-term outcomes and costs. ANGELS, in collaboration with Medicaid, is highlighted as a cost-effective system driving improved survival rates and reduced incidences of IVH in preterm neonates.

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Regionalization of Care for Preterm Babies in Arkansas: A Review of ANGELS Program

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  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 children’s 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 p=0.039 for 500-600gms VtOx p<0.001 for 500-600gms NICHD p<0.001 for 500-600gms ACH p=0.087 for 600-700 gms VtOx p=0.02 for 600-700gms NICHD p<0.005 for 600-700gms

  13. Why We Started: Mortality Data From 1995-2000 ACH p=0.0135 for 500-750 VtOx p<0.0001 for 500-750 NICHD p<0.0001 for 500-750 Vt Ox p=0.0065 for 750-1000 NICHD p=0.026 for 750-1000

  14. Why We Started: IVH Data From 1995-2000 500-750 750-1000 1000-1250 1250-1500 ACH p=0.047 p=0.33 p=0.002 p=0.02 NICHD p<.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 ** * *p<0.05 ** p<0.01

  17. Survival: 2001-2004 *p<0.05; **p<0.01 ** ** * *

  18. Survival: 2001-2004 **p<0.01 ** ** ** ** **

  19. Survival: 2001-2004 p<0.01 UAMS vs. all others

  20. Survival: 2001-2004 P<0.01 at all weights

  21. Grade 3 and 4 IVH Rate *p<0.05 **p<0.01 * ** ** **

  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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