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PEDIATRICS Vol. 108 No. 6 December 2001, pp. 1269-1274

Comparison of Management Strategies for Extreme Prematurity in New Jersey and the Netherlands: Outcomes and Resource Expenditure

John M. Lorenz, MD*, Nigel Paneth, MD, MPH{ddagger},§, James R. Jetton, BA{ddagger}, Lya den Ouden, MD, PhD|| and Jon E. Tyson, MD, MPH

* Department of Pediatrics, Columbia University, New York, New York
{ddagger} Department of Epidemiology, Michigan State University, East Lansing, Michigan
§ Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan
|| Institute for Prevention and Health, Leiden, the Netherlands
Center for Population Health and Evidence-Based Medicine, University of Texas at Houston, Houston, Texas

Objective. To quantify differences in resource expenditure in the perinatal period and long-term outcome of extremely premature infants who received systematically different approaches to neonatal intensive care.

Methods. Perinatal management, mortality, prevalence of disabling cerebral palsy (DCP), and resource expenditure of 2 population-based inception cohorts of extremely premature infants born in the mid-1980s were compared. Electronic fetal monitoring, tocolysis, cesarean section delivery, and assisted ventilation were used to characterize management approaches. Participants included all live births at 23 to 26 weeks’ gestation in a 3-county area of central New Jersey (NJ) from 1984 to 1987 (N = 146) and throughout the Netherlands (NETH) in 1983 (N = 142). Mortality and the prevalence of DCP were the primary outcomes. Numbers of hospital days with and without assisted ventilation were the measures of resource expenditure.

Results. Electronic fetal monitoring (100% vs 38%), cesarean section (28% vs 6%), and assisted ventilation (95% vs 64%) were all more commonly used in NJ than in NETH. Ten percent of NJ deaths occurred without assisted ventilation, compared with 45% of Dutch deaths. A total of 1820 ventilator days were expended per 100 live births in NJ, compared with 448 in NETH. The increase in the number of nonventilator days (3174 vs 2265 days per 100 live births) did not reach statistical significance. Survival to age 2 (46 vs 22%) and the prevalence of DCP among survivors (17.2 vs 3.4%) were significantly greater in NJ at age 2 than in NETH at age 5.

Conclusions. Near universal initiation of intensive care in NJ, compared with selective initiation of intensive care in NETH, was associated with 24.1 additional survivors per 100 live births, 7.2 additional cases of DCP per 100 live births, and a cost of 1372 additional ventilator days per 100 live births.

Key Words: extreme prematurity • mortality • cerebral palsy • neonatal intensive care

Abbreviations: NETH, the Netherlands • NBH, neonatal brain hemorrhage • NJ, New Jersey • POPS, Project on Preterm and Small for Gestational Age Infants • EFM, electronic fetal monitoring • DCP, disabling cerebral palsy • CP, cerebral palsy • CI, confidence interval

Received for publication Mar 26, 2001; Accepted Jul 27, 2001.




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