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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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slide1

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

slide2

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

slide5

*

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 ! ?

slide7

Do We

Truly

Know

What Rx

Is Best ?

slide8

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 ?

slide10

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

slide11

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

slide13

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.
what are the birth demographics for the hudson valley
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%

where are the births
Where are the Births ?

% Birth by County

(n = 29,932 annual births)

New York Vital Statistics 2003

slide17

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)
slide18

Source: SPDS- NICU Module 2004- 2006

Evidence for Impact of Regionalized Services

Last Three

Years

of

Change

3

2

1

slide19

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

slide20

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

70 of all preterm births are late preterm 34 36 weeks gestation

< 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

acknowledgements
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

slide23

Thank

You !

communicating with and educating consumers lower hudson valley perinatal network
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

slide27

*Total discharged home

excludes inhouse transfers

Source: SPDS- NICU Module 2006

the value of cooperativeness the regional neonatal center admissions 1989 1999
The Value of CooperativenessTHE REGIONAL NEONATAL CENTER ADMISSIONS 1989-1999

Growth of

Community

Level II & III

what type of malformations in nys 42 500 births in our catchment area
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

impact of malformations on pediatric health care
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

prevalence of births malformations in hudson valley hospitals y1997 y2005
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

slide37

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