The complications of the newborn period noted in this chapter reflect in part the difficulty of establishing extrauterine life with immature organs. However, some of these complications may also reflect the interventions used in the NICU to sustain life. The question about variations in complication rates as a function of differences in management practices in the NICU was initially raised by a report of the substantial variations in the rate of bronchopumonary dysplasia or chronic lung disease among eight NICUs (Avery et al., 1987). The rates varied from a low of 5 percent in one NICU to almost 40 percent in another and could not be explained by the approaches to the management of respiratory distress syndrome reported by the NICUs, with one exception. The site with the lowest rate of chronic lung disease rarely used mechanical ventilation and tolerated blood gas values out of the physiological normal range. The interpretation of these variations was unclear, however. Even for a given gestational age, the severity of the complications may vary among infants, and without some measure of admission severity or case mix, units with higher rates of complications may simply be admitting sicker infants.
Addressing this issue required the development of admission severity measures, which occurred during the 1990s (Richardson et al., 1998). With the development of two measures that assess the degree to which measures of physiological processes like oxygenation and blood pressure fall outside of the normal range, numerous investigators have documented variations in neonatal outcomes overall (Sankaran et al., 2002) as well as variations in specific complications (Aziz et al., 2005; Darlow et al., 2005; Lee et al., 2000; Olsen et al., 2002; Synnes et al., 2001) that cannot be explained by the severity of the infant's condition on admission. Likewise, after adjusting for the severity of the infants' conditions on admission, substantial differences in management have also been noted (Al-Aweel et al., 2001; Kahn et al., 2003; Lee et al., 2000; Richardson et al., 1999; Ringer et al., 1998). Although most of this work has primarily been done with infants born before 32 weeks of gestation, data that are emerging indicate that such variations are also encountered in the complication rates and management of late-preterm infants
(Blackwell et al., 2005; Eichenwald et al., 2001; Lee et al., 2000; Richardson et al., 2003). Although such variations may have less of an impact on survival and morbidity in the late-preterm infants than in earlier preterm infants, even minor variations among hospitals, such as a week's difference in discharge time between those with the earliest gestational age at discharge compared with those with the latest, may have substantial economic benefits, because these late-preterm infants account for almost half of all NICU stays.
The observation of such variations, some of which appear to be unrelated to the clinical condition of the infant, has prompted efforts to reduce the variation and improve outcomes with existing technologies. As reviewed in a supplement to the journal Pediatrics, several groups are implementing quality improvement strategies to reduce the rates of unnecessary adverse outcomes (Horbar et al., 2003; Ohlinger et al., 2003), with some evidence of success (Chow et al., 2003).
Finding 10-2: Substantial interinstitutional variations in the complication rates for infants born preterm have been documented; and some outcomes, like physical growth, remain suboptimal.
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