ANGELS: Does it ANGELS: Does it Work?Work?Whit Hall MDWhit Hall MD

ANGELSANGELS

EducationEducation GuidelinesGuidelines

ReferralReferral Arkansas, a rural stateArkansas, a rural state 3 areas with practicing 3 areas with practicing

neonatologistsneonatologists Other areas with pediatriciansOther areas with pediatricians

ANGELS: EducationANGELS: Education

Monthly teleconference meetingsMonthly teleconference meetings Face to face interactionFace to face interaction Two way streetTwo way street AHEC contributionAHEC contribution

ANGELS: GuidelinesANGELS: Guidelines

Buy-in to guidelinesBuy-in to guidelines ApneaApnea Pain Pain Hyperbilirubinemia, etcHyperbilirubinemia, etc

Published in AMJPublished in AMJ Contribution of practicing physicians Contribution of practicing physicians

(e.g., recommendation on apnea)(e.g., recommendation on apnea) Evidenced basedEvidenced based

ANGELS: RegionalizationANGELS: Regionalization

Better communicationBetter communication ““Town gown” gap narrowedTown gown” gap narrowed More appropriate (not necessarily More appropriate (not necessarily

more) referralsmore) referrals Is it a good thing for the preterm Is it a good thing for the preterm

neonate??neonate??

Regionalization: HistoryRegionalization: History

Improved outcomes in Wisconsin Improved outcomes in Wisconsin ((Graven, 1977)Graven, 1977)

Improved outcomes in Canada Improved outcomes in Canada (Sankaran K, 2002)(Sankaran K, 2002)

Improved rates of IVH Canada Improved rates of IVH Canada (Synnes (Synnes a, 2002)a, 2002)

Improved outcomes in AR Improved outcomes in AR (Kirby, 1995, (Kirby, 1995, Palmer, Hall RW, 2005) Palmer, Hall RW, 2005)

Maternal referralMaternal referral Numerous articles attesting to that Numerous articles attesting to that Improved outcomes in IVH in California Improved outcomes in IVH in California

(Towers C, 2000)(Towers C, 2000) and Kansas and Kansas (Hall Robert, 2003)(Hall Robert, 2003) Improved mortality outcomes in Improved mortality outcomes in

perinatalperinatal Canadian centers compared Canadian centers compared to free standing children’s hospitals to free standing children’s hospitals (Shah (Shah P, 2005)P, 2005)

Decreased disability Decreased disability (Victorian Study Group, 1991)(Victorian Study Group, 1991)

Decreased mortality Decreased mortality (Kollee, 1999; Warner, 2004; (Kollee, 1999; Warner, 2004; Lubchenco, 1989; Yeast, 1998; Cooper, 1999Obladen, 1994; Lubchenco, 1989; Yeast, 1998; Cooper, 1999Obladen, 1994; Johansson, 2004; Gerlinde, 2005) Johansson, 2004; Gerlinde, 2005)

But….But….

Higher mortality at night in inborn unitsHigher mortality at night in inborn units Better (40%!) if in-house fellow or attending Better (40%!) if in-house fellow or attending (Lee, (Lee,

SK, 2003)SK, 2003)

Observed mortality Observed mortality lessless in hospitals in hospitals withoutwithout residency programs and residency programs and lessless volume (104 vs. volume (104 vs. 62) 62) (Horbar JD, 1997)(Horbar JD, 1997)

Outborn status protective in US Centers Outborn status protective in US Centers (NEOPAIN trial, Rao R, Hall RW, 2006)(NEOPAIN trial, Rao R, Hall RW, 2006)

No difference in mortality after adjusting for No difference in mortality after adjusting for prenatal steroids prenatal steroids (NEOPAIN trial, Palmer KG, Hall RW, (NEOPAIN trial, Palmer KG, Hall RW, 2005)2005) NEOPAIN trial required transfer within 7 hoursNEOPAIN trial required transfer within 7 hours

Problems with Maternal Problems with Maternal Transport in ArkansasTransport in Arkansas

Rural state with long distances to Rural state with long distances to travel in preterm labortravel in preterm labor

Home for threatened preterm labor Home for threatened preterm labor not well developed not well developed

Evolving transport system with Evolving transport system with established neonatal transport systemestablished neonatal transport system

Hospital competitionHospital competition Money, pride, prestigeMoney, pride, prestige

Summation of literatureSummation of literature

Overwhelming support for regionalizationOverwhelming support for regionalization Overwhelming support for maternal Overwhelming support for maternal

transporttransport IVH always decreased in inborn populationIVH always decreased in inborn population Selection bias a problem in all studiesSelection bias a problem in all studies

Refer patients who are “survivable”Refer patients who are “survivable” Outborn babies may require emergency Outborn babies may require emergency

deliverydelivery Abruption, Uterine rupture, prolapsed cord, etcAbruption, Uterine rupture, prolapsed cord, etc

ANGELS: ReferralANGELS: Referral

Regionalization worksRegionalization works A neonatologist does not an A neonatologist does not an

intensive care nursery makeintensive care nursery make Hindrances to regionalizationHindrances to regionalization

MoneyMoney PrestigePrestige

Why UAMS???Why UAMS???

Palmer, Hall, et al, 2005; Fanaroff & Martin, 7th ed, 2002

Mortality 500 - 1000 grams

0

10

20

30

40

50

60

70

80

500-599 600-699 700-799 800-899 900-999

grams

% m

ort

ali

ty UAMS % Mortality

ACH % Mortality

VtOx Mortality

NICHD % Mortality

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

Why We Started: Mortality Data Why We Started: Mortality Data From 1995-2000From 1995-2000

0

5

10

15

20

25

30

35

40

45

50

500-750 751-1000 1001-1250 1251-1500

Grams

% M

orta

lity

Pediatrix

UAMS

ACH

VtOxford

NICHD

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

Why We Started: IVH Data From Why We Started: IVH Data From 1995-20001995-2000

0

5

10

15

20

25

30

35

500-750 751-1000 1001-1250 1251-1500

Grams

% S

ev

ere

IV

H

UAMS

ACH

NICHD

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

EvidenceEvidence

Better outcomes with inborn Better outcomes with inborn delivery in ARdelivery in AR

Need for educationNeed for education Medicaid deliveries Medicaid deliveries

Large impact (55% coverage)Large impact (55% coverage) Easy to work withEasy to work with CentralizedCentralized

Survival: 2001-2004Survival: 2001-2004

0

10

20

30

40

50

60

70

500-750 Grams

UAMS

Vt Ox

Pediatrix

NICHD

ACH

ADH (non UAMS)

** **p<0.05

** p<0.01

Survival: 2001-2004Survival: 2001-2004

74

76

78

80

82

84

86

88

90

92

751-1000 Grams

UAMS

Vt-Ox

Pediatrix

NICHD

ACH

ADH (non UAMS)

** **

**

*p<0.05; **p<0.01

Survival: 2001-2004Survival: 2001-2004

84

86

88

90

92

94

96

98

100

1001-1500 Grams

UAMS

Vt Ox

Pediatrix

NICHD

ACH

ADH (non UAMS

** **** *

***

**p<0.01

Survival: 2001-2004Survival: 2001-2004

78

80

82

84

86

88

90

92

All VLBW

UAMS

Vt Ox

Pediatrix

NICHD

ACH

ADH (non UAMS)

p<0.01 UAMS vs. all others

Survival: 2001-2004Survival: 2001-2004

0

10

20

30

40

50

60

70

80

90

100

500-750g

751-1000g

1001-1500g

All

UAMS Medicaid

Non UAMS Medicaid

P<0.01 at all weights

Grade 3 and 4 IVH RateGrade 3 and 4 IVH Rate

0

5

10

15

20

25

30

500-750g 751-1000g 1001-1500g All

UAMS

ACH

***

** **

*p<0.05

**p<0.01

Why the Improved Why the Improved Outcomes at UAMSOutcomes at UAMS

Maternal TransportMaternal Transport Strong OB/Perinatal programStrong OB/Perinatal program ACH backupACH backup Nursing experienceNursing experience UAMS administration backupUAMS administration backup In house neonatal coverageIn house neonatal coverage MedicaidMedicaid

160165170175180185190195200205210

2001 2002 2003 2004

No of Admissions

ANGELS

Number of UAMS VLBW Admissions

What We KnowWhat We Know

UAMS has better survival in VLBW UAMS has better survival in VLBW neonatesneonates

Less IVH in the inborn populationLess IVH in the inborn population ANGELS has increased inborn ANGELS has increased inborn

deliverydelivery Back-up of ACHBack-up of ACH Medicaid is in a good position to Medicaid is in a good position to

advocate for better outcomes advocate for better outcomes regardless of pride and prestigeregardless of pride and prestige

What We Must ResearchWhat We Must Research

CostCost Initial hospitalInitial hospital Long termLong term

Long term outcome and satisfaction Long term outcome and satisfaction of familiesof families

Quality of survivalQuality of survival

ConclusionConclusion

ANGELS is building a better medical systemANGELS is building a better medical system IVH rates are markedly improved; survival IVH rates are markedly improved; survival

is modestly affected in the system is modestly affected in the system More research is needed on long term More research is needed on long term

outcomes and costsoutcomes and costs ANGELS/Medicaid is a smart, cost effective ANGELS/Medicaid is a smart, cost effective

system who cares for her clients, especially system who cares for her clients, especially compared to other programs (FEMA)compared to other programs (FEMA)

Funding should remain intact for AHRQ, Funding should remain intact for AHRQ, Medicaid, and ANGELSMedicaid, and ANGELS