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Assessing restructuration of perinatal care in Ile de France
1998-2009
C. Crenn Hebert, APHP, Colombes, Perinatal Network Hauts de Seine North, PERINAT-ARHIF, France
ORAH 2009
Create health information system at regional level
Dr C. Crenn Hebert, APHP, Perinatal Network Hauts de Seine North, FranceDr C. Menguy, Hal Montreuil Seine Saint-Denis, FranceE. Lebreton, « PERINAT-ARHIF » , Paris, FranceG. Echardour, ARHIF, Paris, FranceDr A. Serfaty APHP, Hal Trousseau, Perinatal Network Eastern Paris, FranceJ. Zeitlin INSERM, UMR S953, UPMC Univ Paris 06, France
Content
• Background: Ile de France region and policies• Method for creating information system:
– Health certificate– Hospital discharge summary
• Results: – Perinatal structures– Perinatal indicators– Focus on Hauts de Seine district
• Discussion
• Conclusion
Ile de France : > 1/5 French births
Background: perinatal policies Perinatal care: a priority
by Regional health authority
Objective: 80% very preterm births in level III perinatal centre (PC III)
Level I: maternity unit without neonatal care Level IIA: on-site neonatal care Level IIB: on-site neonatal intensive care unit Level III: on-site neonatal resuscitation Specialised PCIII: foetal medicine or neonatal surgery
*L'action collective périnatalité en Ile de France, 1996-2000, A. Serfaty, E. Papiernik, ed ENSP 2005
Regional Health Organization Schemes:
Assess and elaborate successive schemes (1994, 1999, 2006)
In partnership with the regional health authority and perinatal health clinicians
The need for data ….Regional birth commission Survey in 1998
1998: 8 Perinatal Centres level III+ 2 specialised PCIII (foetal medicine or neonatal surgery)
135 maternity units- unequal distribution of PCIII over the 8 districts
1998: Regional birth commission Survey:
only 60% of very preterm births in PC III
59%
40%
82%
52%
70%59%
64%
57%
Regionalisation of very preterm birth sites in the Paris region in 1998 ; Annie Serfaty et al. Santé publique 2003, vol 15, no 4, pp. 491-502
Creating information system: method
• Criteria:Use of existing databasesRoutine dataData are available quicklyData are validated
• Involving perinatal health professionals:>Analysis to be shared between regional health
authority and data producer
1- Health certificates• First one at birth (live birth): indicators of birth certificate (BC)
parental demographics, antenatal period, delivery, newborn characteristics (gestational age, birth weight…), first week events(followed by 2nd certificate at 9 months, 3rd certificate at 24 months)
• Sent to maternal and child protection services in district of parents residence
• Common regional database from all districts: in progress from 2002
Maternity unit, Neonatal unit
Birth certificates
MCPS of residence district(anonymous files)
Hospital
Health ministry
Data managementCommon regional data baseStatistics
ValidationModification
Analysis validated by regional medical group of MCPS Drs
HEALTH CERTIFICATES: Each livebirth (BC)
MATERNAL AND CHILD PROTECTION SERVICES: MCPSDistrict of residence
“Perinat-arhif” statisticianEpidemiological research unitRegional health authority
2- Hospital Discharge Data System : (French PMSI)
• Hospital Discharge Summary : perinatal indicators set in IDF region, for every hospital, depending of place of residence pregnant or mother stay newborn (live or stillborn > 2009) or neonate stay until 2008, no gestational age is notified
• But without any link Mother-Baby!
“PERINAT-ARHIF” system
Maternity unit, Neonatal unit
MID
HDDS UDS
Hospital Discharge SummaryLINKING FILE( anonymous files)
Hospital
e-PMSIHealth Ministery
Data managementPerinatal data baseStatistics
ValidationModification
Analysis validated by Perinatal health networks Medical committees
Quality ControlAudits
Hospital Discharge Data System : HDDSUnit Discharge Summary: UDS
Medical Information Department: MID
Hospital Discharge Summary+ Linking File: mother and baby+ direct validation process+ audits
=“PERINAT-ARHIF” system
“Perinat-arhif” teamRegional health authority
www.perinat-arhif.org
Download application programs 2006, 2007
Patient flows
But also:
- Regional summary tables
- Hospital summary tables …
85 perinatal indicators compatible:
. AUDIPOG (www.audipog.net)
. EUROPERISTAT (www.europeristat.com)
Completeness of the data
• Birth Certificates (BC)
2007
93.3%
• Hospital Discharge Summary (HDS)
2007
95.4%
Comparison with civil registration « INSEE »
Great heterogeneity between each district
But giving feed-back to professionals seems to improve the reliability
Completeness BC/district/ 2006 and 2007 / source INSEE civil registration
80,0%
85,0%
90,0%
95,0%
100,0%
% 2006 % 2007
Paris
Seine-et-Marne
Yvelines
Essonne
Hauts-de-Seine
Seine-saint-Denis
Val-de-Marne
Val d'Oise
Completeness HDS 2006 AND 2007 / INSEE
80,0%
85,0%
90,0%
95,0%
100,0%
% 2006 % 2007
Paris
Seine-et-Marne
Yvelines
Essonne
Hauts-de-Seine
Seine-saint-Denis
Val-de-Marne
Val d'Oise
Results
Perinatal structures
Perinatal indicators
Focus on Hauts-de-Seine district
Restructuring perinatal care in IDF
1998 170 000 births
by IDF residents : source civil registration INSEE
135 maternity units
8 PC III
2007 179 264 births
by IDF residents :(INSEE)
105 maternity units
14 PC III15 in 200816 in 2009
2007 – 14 PC III (incl spec PCIII)
Deliveries and perinatal centre type (source HDD)
PC I : decrease
PC II : stable
PC III: increase
34,2 33,1 30,8
24,8 23,925,2
19,719,5 19,6
21,4 23,5 24,4
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008
Type I Type IIA Type IIB Type III
Newborns with birth weight <1500g (source HDD)
4,5 2,9 3,1
6,95,4 5,9
1211,6 12,7
76,680,1 78,3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008
Type I Type IIA Type IIB Type III
2007 80% Newborns <1500g born in CP III (source HDD)
74%
83%
77%
81%
76%
87%
81%
83%
2007 78% Newborns <32 wk born in PC III (source BC)
72%
83%
75%
81%
73%
78%
80%
83%
0% to 2,8% gestational age missing
Focus on Hauts-de-Seine (HdS) district
Differences in populations between north and south of district (2007)
source HDD
Residents in North
• <1500g : 1,04%*
Residents in South
• <1500g : 0,77%*
* p= 0.03
Impact of not having a PC III? Differences in health care
Hauts de Seine North/ Hauts de Seine South (2007) (source HDD)
Residents in North
< 1500g born in PCIII: 74,4%*
Multiple delivery in PCIII:23,5%**
Residents in South
< 1500g born in PCIII: 91,3%*
Multiple delivery in PCIII 62,7%**
* p =0.003 **p<0.0001
2008 15th PC III in Hauts de Seine North
2008 Newborns <1500g born in PC III (source HDD)
81%
77%
77%
85%
72%
90%
84%
86%
Results of opening PC III in North 2008 Hauts de Seine North/ Hauts de Seine South (source HDD)
Residents in North
• < 1500g born in PCIII: 83,6% (ns)
• Multiple delivery in PCIII: 45,3%**
Residents in South 92
• < 1500g born in PCIII: 87,5% (ns)
• Multiple delivery in PCIII: 59,7%**
**p=0.001
Results of opening PC III in North 2008 Hauts de Seine North/ Hauts de Seine South (source HDD)
Residents in North 92
• < 1500g born in PC I or IIA: 7,0%
• Multiple delivery in PC I or IIA: 39,9%**
Residents in South 92
• < 1500g born in PC I or IIA: 8,0%
• Multiple delivery in PCI or IIA: 26,8%**
**p=0.002
Discussion
• Change in perinatal structures may be monitored at different levels
• Routine data information important for planning of maternity care
• Evolution in perinatal health indicators may also reflect:– Changes in health of the population – Changes in medical practices among health
professionals
Discussion
• Relevance of the initial indicator is questionable (rate of in-born very preterm birth)
• In Hauts de Seine district, previous PC level IIB is upgraded to PC level III
• Hospital discharge data provided only birth weight , but similar data are obtained from birth certificates with gestational age in 2007
Thoroughness and accuracy of the data:hard to achieve…
Conclusion
• Combining analysis from 2 routine information systems helps to provide validated data for a regional vision of restructuration
• Analysis at perinatal network level and smaller territorial scales is important to access population needs and the adequacy of health care provision.
Thank you for your attention
Any Questions?
1994-2009: Government policies in France
Change in organization of perinatal care– Level I: maternity unit without neonatal care
– Level IIA: on-site neonatal care
– Level IIB: on-site neonatal intensive care unit
– Level III: on-site neonatal resuscitation
Change in medical practice• Toward regionalisation: place of birth according to risk level• In utero-transport to avoid negative effect of post-natal
transport
2007 – 14 PC III27743
18624
19899
17932
Paris30820
24937
20331
18978
Living Births district volumes differ, PC III capacities also
922
923
Cli Sainte IsabelleHôp Américain
Hôp Max Fourestier Hôp BeaujonCli Lambert
Hôp Louis Mourier
CH Neuilly Courbevoie
IH Franco-Britannique
Cli Les Martinets
Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France
© 2008 ARHIF-APHP-CRAMIF tous droits réservés
Établissement AP-HP
Établissement Public de Santé
Établissement PSPH
Établissement Privé à but non lucratif
Établissement Privé à but lucratif
CPN III
CPN II B
CPN II A
CPN I
Réseau Périnatal 92 NordRéseau Périnatal 92 Nord
921
922
912
CMC Foch
CH des Quatre Villes (site Saint-Cloud)
CH des Quatre Villes (site Sèvres)
Hôp privé Antony
CHU Antoine Beclère
CH d' Orsay Cli de l' Yvette
Pôle de santé du Plateau (site Meudon)
Cli Ambroise Paré
Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France
© 2008 ARHIF-APHP-CRAMIF tous droits réservés
Établissement AP-HP
Établissement Public de Santé
Établissement PSPH
Établissement Privé à but non lucratif
Établissement Privé à but lucratif
Réseau Périnatal 92 SudRéseau Périnatal 92 Sud
CPN III
CPN II B
CPN II A
CPN I
Possibilité de collaboration avecRéseau Périnatal 92 Nord