1
Peds PLACE Changes effected CAR Effects in the SubC Survival 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 Pediatrics University 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. Objectives Objectives Understand the problems associated with Understand the problems associated with community neonatology and deregionalization community neonatology and deregionalization Understand possible solutions utilizing Understand possible solutions utilizing telemedicine leading to appropriate telemedicine leading to appropriate regionalization regionalization Deregionalization leads to : : Increase in the number of NICU’s and complexity of cases cared for in smaller hospitals Increase in neonatal mortality So why not deliver all babies in an appropriate level of care? Pressures to Deregionalize : : Prestige Money: improved payer mix Managed care organizations Improved public perception Philanthropy enhanced Deregionalization : Neonatologists care for 60% normal newborns BUT 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 delivery Different population when unable to be referred Larger neonates do as well in smaller nurseries Smaller nurseries : Community nurseries are here to stay Many have one or 2 neonatologists Continuous coverage required Need to transport appropriately Telemedicine Direct links with 10 going to 20 nurseries Direct communication using videoconferencing Give and take dialogue Pediatrics Physician Learning Peds Pediatrics Physician Learning Peds PLACE PLACE Program High risk OB conferences weekly MFM consults available 24/7 Telemedicine census rounds with all major nurseries from 8:15-8:30 MWF Peds PLACE, with one week monthly devoted to neonatal education Neonatal 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 AR Save 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 nurseries If only 25% delivered there, potential for 3,000 lives saved The future can: Support for days off utilizing nurse practitioner, practicing pediatrician Encourage neonatal coverage of community hospitals Establish state-of-the-art guidelines Increase 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 2004 500-1000gm 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 2002 Discussion 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 weights Percent Regionalization in AR: Comparison of survival for 2001-2004 Survival 0.57 0.63 0.85 84 84 † 96 96 85 85 † 91 91 Total Total 95 95 † 99 99 95 95 † 99 99 1001-1500 1001-1500 grams grams 85 85 † 97 97 85* 85* 92 92 751-1000 grams 751-1000 grams 63 63 † 85 85 57* 57* 69 69 501-750 grams 501-750 grams Non-UAMS Medicaid Non-UAMS Medicaid (Percent (Percent UAMS Medicaid UAMS Medicaid (Percent) (Percent) Non-UAMS-All Non-UAMS-All (Percent) (Percent) UAMS All UAMS All (Percent) (Percent) Weight Weight *p<0.05; † p<0.01 Table. Comparison between all UAMS deliveries and all state deliveries and between all Medicaid deliveries. Survival by Birthweight Deliveries by Birthweight 500-1000 gram neonates most at risk Technology Employed Originating site: Originating site: Video, audio camera TV screen Cable: Cable: 750 kb/sec Distant site: Distant site: Video, audio camera TV screen Results Embedding of academic practice into local community Enhanced collegiality Give and take dialogue Learning occurred at both ends Facilitation of back transport Examples –Surfactant, immunization practices Changes in Patterns of Delivery Changes in Patterns of Delivery for LBW Infants in Rural/Outlying Are for LBW Infants in Rural/Outlying Area Highest-risk infants residing >80 miles from UAM Highest-risk infants residing >80 miles from UAMS likely likely to be delivered at UAMS after ANGELS implemen to be delivered at UAMS after ANGELS implemen 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, socioe race/ethnicity. † p<0.05 † † ANGELS Mortality before and af Telemedicine 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
