Peds PLACE

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Community Based Research and Education (CoBRE) Core Facility. R. Whit Hall, MD, J. Hall-Barrow, EdD, and Edgar Garcia-Rill, PhD, Center for Translational Neuroscience and Dept. of Pediatrics University of Arkansas for Medical Sciences, Little Rock, AR. CAR Effects in the SubC. - PowerPoint PPT Presentation

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Peds PLACE

Changes effected

CAR Effects in the SubCSurvival across sites

Support

Intervention

Current and planned telemedicine sites

Conclusions

Potential

Introduction

Abstract

Community Based Research and Education (CoBRE) Core Facility.R. Whit Hall, MD, J. Hall-Barrow, EdD, and Edgar Garcia-Rill, PhD,

Center for Translational Neuroscience and Dept. of PediatricsUniversity of Arkansas for Medical Sciences, Little Rock, AR

Background and Objective We established a network of 15 sites, with 10 more to be added within the year, using T1 lines to link telemedicine units with real-time teleconferencing and diagnostic quality imaging. Fifteen units were placed in neonatal Intensive Care Units (NICU) and 10 more in other delivery sites. We carried out weekly combined obstetric and neonatal educational conferences to establish guidelines for the care of premature babies and other common pediatric illnesses with outlying clinicians caring for mothers and their newborns. Initial studies evaluated the impact of telemedicine on regionalization of newborn care, and of physician and other caregiver satisfaction with the educational part of the program.Methods Patterns of delivery were assessed through a linked Medicaid database before and after the telemedicine initiative to determine if the most at risk neonates were transferred to the perinatal center for delivery. Additionally, clinician satisfaction with the educational conference, combined with translational educational sessions, broadcast through telemedicine to practicing clinicians was assessed. Results Survey results from practicing clinicians revealed that they would change their practice to conform to the educational guidelines established in the educational conferences. Medicaid deliveries at the perinatal center before and after the telemedicine initiative in 2003 are shown in the Table.

ObjectivesObjectivesUnderstand the problems associated with community Understand the problems associated with community neonatology and deregionalization neonatology and deregionalization Understand possible solutions utilizing telemedicine leading Understand possible solutions utilizing telemedicine leading to appropriate regionalizationto appropriate regionalization

Deregionalization leads to::Increase in the number of NICU’s and complexity of cases cared for in smaller hospitalsIncrease in neonatal mortalitySo why not deliver all babies in an appropriate level of care?

Pressures to Deregionalize::PrestigeMoney: improved payer mixManaged care organizationsImproved public perceptionPhilanthropy enhanced

Deregionalization:Neonatologists care for 60% normal newbornsBUT general pediatricians only receive 4 months of neonatal intensive care compared to 8 months a decade ago

–Less able to care for moderately sick newborns in the community

Many neonates cannot be transferred prior to deliveryDifferent population when unable to be referredLarger neonates do as well in smaller nurseries

Smaller nurseries:Community nurseries are here to stayMany have one or 2 neonatologistsContinuous coverage requiredNeed to transport appropriatelyNeed to be supported

Telemedicine Direct links with 10 going to 20 nurseriesDirect communication using videoconferencingGive and take dialogue

Pediatrics Physician Learning Peds PLACEPediatrics Physician Learning Peds PLACE

Program

High risk OB conferences weeklyMFM consults available 24/7Telemedicine census rounds with all major nurseries from 8:15-8:30 MWFPeds PLACE, with one week monthly devoted to neonatal educationNeonatal consults 24/7

–Examples, cases

Mortality before and after implementation of PedsPLACE. Comparing the two years before implementation (2001-2003) to the two years after implementation in 4/2003 (2003-2005), mortality has decreased in every type of delivery site. The numbers for 2006-2008 will not be available until early next year, however, these data suggest that the PedsPLACE telemedicine program is having a real impact on survival. Note the higher mortality rate at UAMS compared to other sites, indicative of the high risk population and higher percentage of VLBW neonates. Mortality is lower for Medicaid patients in every birth hospital category. This may be due in part to faster referral to ACH (increased referrals within 24 hours).

This program has the potential to:Save 5 lives per year for every 50 neonates <1000 g delivered appropriately in ARSave 7 severe IVH per year in AR for every 50 neonates delivered appropriately (cost of one IVH~$200,000) In US, 75% of VLBW newborns are delivered in smaller nurseriesIf only 25% delivered there, potential for 3,000 lives saved

The future can:Support for days off utilizing nurse practitioner, practicing pediatricianEncourage neonatal coverage of community hospitalsEstablish state-of-the-art guidelinesIncrease appropriate referrals

There is a strong trend towards deregionalization Telemedicine can build bridges leading to appropriate regionalization and better care

Supported by USPHS grant from NCRR, P20 RR20146, as well as the ANGELS program at UAMS and Medicare of Arkansas.

Birthweight 2001 2002 2003 2004500-1000gm 27.6% 19.9% 31.4% 34.5%*

1001-1500gm 32.7% 24.2% 29.7% 30.6%

1501-2000gm 20.3% 14.8% 24.1% 20.0%

2001-2500gm 8.0% 7.9% 8.2% 7.5%

Table. *p<0.05 after 2002Discussion and Conclusions Telemedicine is an effective way to translate evidence based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the perinatal center.

Supported by NCRR COBRE award RR20146.

7 8

8 0

8 2

8 4

8 6

8 8

9 0

9 2

A l l V L B W

U A M S

V t O x

P e d i a t r i x

N I C H D

A C H

N o n U A M S a l l

P<0.01 vs. UAMS at allweights

Percent

Regionalization in AR: Comparison of survival for 2001-2004

Survival

0.570.630.85

8484††96968585††9191TotalTotal

9595††99999595††99991001-15001001-1500gramsgrams

8585††979785*85*9292751-1000 grams751-1000 grams6363††858557*57*6969501-750 grams501-750 grams

Non-UAMS MedicaidNon-UAMS Medicaid(Percent)(Percent)

UAMS MedicaidUAMS Medicaid(Percent)(Percent)

Non-UAMS-AllNon-UAMS-All(Percent)(Percent)

UAMS AllUAMS All(Percent)(Percent)WeightWeight

*p<0.05; †p<0.01

Table. Comparison between all UAMS deliveries and all statedeliveries and between all Medicaid deliveries.

Survival by Birthweight

Deliveries by Birthweight

500-1000 gram neonates most at risk

Technology EmployedOriginating site:Originating site:

Video, audio cameraTV screen

Cable:Cable:750 kb/sec

Distant site:Distant site:Video, audio cameraTV screen

ResultsEmbedding of academic practice into local communityEnhanced collegialityGive and take dialogueLearning occurred at both endsFacilitation of back transportExamples

–Surfactant, immunization practices

Changes in Patterns of DeliveryChanges in Patterns of Deliveryfor LBW Infants in Rural/Outlying Areasfor LBW Infants in Rural/Outlying Areas

Highest-risk infants residing >80 miles from UAMS were moreHighest-risk infants residing >80 miles from UAMS were morelikelylikely

to be delivered at UAMS after ANGELS implementation to be delivered at UAMS after ANGELS implementation

0%

5%

10%

15%

20%

25%

30%

35%

40%

2001 2002 2003 2004

<1000 grams 1000-1499 grams

1500-1999 grams 2000-2499 grams

Regression-adjusted estimates controlling for maternal risks, insurance source, socioeconomic characteristics, andrace/ethnicity. †p<0.05

ANGELS

Mortality before and afterTelemedicine

0 . 0 0 %

0 . 2 0 %

0 . 4 0 %

0 . 6 0 %

0 . 8 0 %

1 . 0 0 %

1 . 2 0 %

1 . 4 0 %

1 . 6 0 %

1 . 8 0 %

U A M S L a r g e

N I C U

S m a l l

N I C U

L a r g e

n o

N I C U

S m a l l

N o

N I C U

B e f o r e T e l e m e d i c i n e

A f t e r t e l e m e d i c i n e

2001-2003 vs. 2003-2005