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Trends in Mortality and Morbidity for Very Low Birth Weight Infants, 1991–1999

Jeffrey D. Horbar, MD^*,, Gary J. Badger, MS, Joseph H. Carpenter, MS, Avroy A. Fanaroff, MBBCh^||, Sarah Kilpatrick, MD, PhD^¶, Meena LaCorte, MD^#, Roderic Phibbs, MD^**, Roger F. Soll, MD^*, for the Members of the Vermont Oxford Network

^* University of Vermont Department of Pediatrics, Burlington, Vermont
Vermont Oxford Network, Burlington, Vermont
University of Vermont Department of Medical Biostatistics, Burlington, Vermont
^|| Case Western Reserve University, Rainbow Babies and Children’s Hospital, Cleveland, Ohio
^¶ University of Illinois at Chicago, Chicago, Illinois
^# The Brooklyn Hospital Center, New York, New York
^** University of California San Francisco, California

	ABSTRACT

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Background. Medical care for very low birth weight (VLBW) infants and their mothers has changed dramatically during the 1990s, yet it is unclear how these changes have affected mortality and morbidity.

Objective. We used the Vermont Oxford Network Database to identify trends in clinical practice and patient outcomes for VLBW infants born from 1991 to 1999.

Methods. Logistic regression was used to evaluate temporal trends in practices and outcomes while adjusting for patient characteristics and accounting for clustering of cases within hospitals.

Results. There were 118 448 infants 501 to 1500 g from 362 neonatal intensive care units enrolled in the Network Database from 1991 to 1999. Prenatal care, cesarean section, multiple births, antenatal steroids, and 1-minute Apgar scores increased during this period, as did the use of nasal continuous positive airway pressure, high-frequency ventilation, surfactant, and postnatal steroids. The proportion of white infants decreased; the proportions of Hispanic infants and those of other races increased. The crude and adjusted rates of mortality, pneumothorax, intraventricular hemorrhage (IVH), and severe IVH declined from 1991 to 1995, whereas from 1995 to 1999, the rates of mortality, IVH, and severe IVH did not change significantly, and pneumothorax increased.

Conclusions. There have been major changes in both obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades-long trend of improving outcomes for these infants.

Key Words: very low birth weight • neonate • mortality • morbidity • intraventricular hemorrhage • pneumothorax • antenatal corticosteroids • surfactant • network • trends

Abbreviations: CLD, chronic lung disease • VLBW, very low birth weight • NICU, neonatal intensive care unit • IVH, intraventricular hemorrhage • NICHD, National Institute of Child Health and Human Development

	INTRODUCTION

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In the 1990s, new approaches emerged for both the obstetric management of preterm birth and the neonatal care of the prematurely born infant. These included the widespread use of antenatal corticosteroids for women at risk for preterm delivery,¹ surfactant for the prevention and treatment of neonatal respiratory distress syndrome,² postnatal steroids for chronic lung disease (CLD),³ and new modes of respiratory support for neonates with respiratory distress.^4–6 Furthermore, structural changes in the health care system have resulted in the deregionalization of perinatal and neonatal care.⁷ It is uncertain how these developments have affected routine care and what impact they have had on patient outcomes. In particular, it is unclear whether the historical trend of steadily improving mortality for very low birth weight (VLBW) infants that has been observed over the past decades has continued throughout the 1990s.^8–10

To address this question, we used the Vermont Oxford Network Database to identify trends in medical practices and patient outcomes for infants with birth weights of 501 to 1500 g born from 1991 to 1999.¹¹ Results for infants born in 1990 have been previously reported.¹²

	METHODS

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Vermont Oxford Network
The Vermont Oxford Network is a voluntary collaboration of health professionals whose mission is to improve the quality and safety of medical care for newborn infants and their families through a coordinated program of research, education, and quality improvement.¹¹ In support of this mission, the Network maintains a database for infants with birth weights of 401 to 1500 g. Members adhere to uniform definitions included in the Network’s Database Manual of Operations.¹³

Infants with birth weights of 401 to 1500 g (501 to 1500 g before 1996) are eligible for inclusion in the database if they were born at a Network center or were transferred to it within 28 days of birth. This report is based on an analysis of the data for all eligible infants born from 1991 and 1999 with birth weights between 501 and 1500 g.

Statistical Methods
Statistical analyses were performed using SAS statistical software version 8.1 (SAS Institute, Cary, NC). The significance associated with changes over time in the dichotomous intervention and outcome measures were first analyzed based on logistic models containing only time as a predictor variable. Next, multivariate models were fit to evaluate changes over time while adjusting for changes in infant characteristics (gestational age, race, gender, location of birth, multiple birth, and size <10th percentile for gestational age). Although the tabular results are presented by year, the logistic models included time as a continuous measure coded as days from January 1, 1991. All significance tests associated with terms in the model reflect adjustment for clustering of infants within institutions.¹⁴ Separate post hoc analyses were performed for the time periods 1991 to 1995 and 1995 to 1999 to examine differences in trends between the early and late 1990s. Changes over time for continuous measures were evaluated using nested analysis of variance (SAS, Proc Mixed) with hospital as the unit-of-analysis.

Two sets of analyses were performed for each outcome measure. The first set was based on all infants admitted to any of the 362 neonatal intensive care units (NICUs) that participated in the Network Database for 1 or more years during the study period. The second set was restricted to infants from the 39 NICUs that participated in the Network Database for all 9 years of the study period.

	RESULTS

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A total of 118 448 VLBW infants born from January 1, 1991, to December 31, 1999, were enrolled in the Vermont Oxford Network Database by 362 participating institutions. Three hundred thirty-one of the institutions were in North America (325 United States, 6 Canada); 31 institutions represent 17 countries around the world. Thirty-nine institutions, all in North America (38 United States, 1 Canada), participated in the Network during the entire 9-year study period.

The characteristics, interventions, and outcomes for study infants from all 362 institutions are shown in Table 1; those for infants from the 39 institutions that participated for 9 years are shown in Table 2. The racial and ethnic composition of the database changed over time with a decrease in the proportion of white infants and increases in the proportions of Hispanic infants and those of other races. The proportion of multiple births increased. The 1-minute Apgar scores of study infants increased from 1991 to 1999, while the mean birth weight decreased slightly. These temporal trends were statistically significant in both groups of institutions.

There were also major changes in the interventions used after birth. The proportion of infants treated with surfactant, nasal continuous positive airway pressure, and postnatal steroids increased significantly from 1991 to 1999. The proportion of all infants treated with high frequency ventilation increased from 7.7% in 1991 to 23.6% in 1999. The proportion of infants treated with conventional ventilation decreased significantly over this time period from 80.8% to 71.6%. The proportion of infants treated with any assisted ventilation (either high frequency or conventional ventilation) also decreased from 80.8% in 1991 to 74.4% in 1999. These changes were also significant in the 39 institutions that participated in all 9 study years.

The use of postnatal corticosteroids reached a peak in 1997 (28.5%) and then declined slightly by 1999 (26.5%).

Mortality trends for infants enrolled at all 362 institutions and for those enrolled at the subset of 39 institutions common throughout the study period are nearly identical (Fig 1). Mortality decreased from 18% in 1991 to 15% in 1995, remaining relatively constant for the remainder of the study period.

View larger version (13K): [in this window] [in a new window]   Fig 1. Mortality for infants 501 to 1500 g, 1991 to 1999, at all 362 network hospitals (solid line) and at 39 hospitals participating in all 9 years (dashed line).

View larger version (19K): [in this window] [in a new window]   Fig 2. Mortality for infants 501 to 1500 g, 1991 to 1999, by birth weight category at all 362 network hospitals. (501–750 g: diamond markers, 751–1000 g: square markers, 1000–1500 g: circle markers).

View larger version (17K): [in this window] [in a new window]   Fig 3. Pneumothorax for infants 501 to 1500 g, 1991 to 1999, by birth weight category at all 362 network hospitals. (501–75 g: diamond markers, 751–1000 g: square markers, 1000–1500 g: circle markers).

View larger version (20K): [in this window] [in a new window]   Fig 4. IVH for infants 501 to 1500 g, 1991 to 1999, by birth weight category at all 362 network hospitals. (501–75 g: diamond markers, 751–1000 g: square markers, 1000–1500 g: circle markers).

	DISCUSSION

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The similarity of findings in the total group of 362 institutions with those in the subgroup of 39 institutions that participated in all 9 study years and the persistence of statistically significant temporal trends after adjusting for changes in infant characteristics suggest that the trends we observed cannot be attributed to changes in either institutional or patient level case mix.

Although not a population-based sample, the Vermont Oxford Network does provide a detailed description of care practices and outcomes at a wide range of neonatal intensive care units. The 26 000 infants in the database for 1999 include over 40% of the 57 400 VLBW infants born in the United States that year.¹⁵

Our findings are consistent with those of the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network, a group of 14 academic medical centers in the United States. The NICHD Network reported a decline in VLBW mortality from 26% in 1988, to 20% in 1991 and 16% in 1995 and 1996.^16–19 Data from more recent years are not yet available.

There were several important changes in obstetric and neonatal practices during the 9-year interval of this study. Can any of these changes explain the improvements in mortality and morbidity that we observed? Because only 2 of the interventions, antenatal steroids and postnatal surfactant, have effects on mortality that are supported by strong evidence from multiple randomized controlled trials, these deserve primary consideration.

Antenatal corticosteroid therapy for women at risk for preterm delivery improves survival in their infants and reduces the risks for respiratory distress syndrome, mortality, and IVH.^1,20 Antenatal steroid use in our Network increased threefold from 1991 to 1999 (24% to 72%). Although we did not observe a corresponding decrease in the frequency of respiratory distress syndrome, an effect that would be expected based on the induction of fetal lung maturation by antenatal steroids, this may result from our definition of respiratory distress syndrome that includes even mild cases. The decrease in the proportion of infants requiring any assisted ventilation suggests that the severity of respiratory distress may in fact have decreased in association with increasing antenatal steroid use.

Surfactant therapy for preterm infants with or at risk for respiratory distress syndrome improves survival and reduces the risk for pneumothorax.^2,21–24 Earlier treatment has been shown to be more beneficial than later treatment.²¹ In 1990, 49% of the infants 501 to 1500 g reported to the Vermont Oxford Network Database received surfactant treatment.¹² Surfactant use then increased further to 53% in 1991 and 62% in 1999. Although we only observed a modest increase in the overall proportion of infants treated with surfactant between 1991 and 1999, it is likely that more optimal timing and dosage schedules were implemented during the 1990s as neonatologists became more experienced with this therapy and as additional study results became available. Preliminary data from the Vermont Oxford Network showing a decrease from 1998 to 1999 in the time after birth at which the first dose of surfactant was given support this possibility.²⁵ It is likely that the trend toward earlier surfactant administration began even earlier in the decade and that more optimal surfactant treatment strategies as well as an increasing proportion of treated infants played a role in improving outcomes. Furthermore, antenatal steroids and surfactant are synergistic.²⁶ Thus, the effects of even modest increases in surfactant use may have been amplified by the concurrent increase in antenatal steroid therapy. We speculate that both antenatal steroids and surfactant played a role in the improved survival and reduced pneumothorax rates observed from 1991 to 1995.

The large increase in multiple births over the 9 years (from 20% to 27%) parallels the trend seen in data from the United States as a whole²⁷ and is similar to that observed by the NICHD Neonatal Research Network (20% to 26%).²⁸ The Vermont Oxford Network Database does not include information about the use of assisted reproductive technology, the most likely cause for the observed increase.

Despite the introduction of surfactant and newer ventilation strategies, CLD remains a major complication for VLBW infants. Data for chronic lung disease were not available in the database for all of the years under study and therefore are not included in this report. However, we do have data for the use of postnatal corticosteroid therapy for the prevention and treatment of CLD. We observed that the peak rate of postnatal steroid treatment occurred in 1997 (28.5%) with subsequent small decreases in the overall Network rates in 1998 (28.2%) and 1999 (26.5%). Preliminary data for infants born in 2000 show an additional decrease in postnatal steroid use to 23%,²⁹ suggesting that a more cautious approach has resulted from concerns about potential short-term and long-term adverse effects of postnatal steroids.³⁰

We do not have data on long-term neurodevelopmental disabilities. Given the high rates of disability, particularly in the least mature infants, it will be important to determine whether improvements in survival and IVH have been associated with changes in long-term outcomes.^31,32

How can we explain the leveling off in mortality and morbidity during the second half of the 1990s? There are at least 3 potential explanations. First, we may have reached the limits of current technology to support preterm infants at gestational ages near the limits of viability. Second, inappropriate use of some interventions may have resulted in adverse events. Inappropriate use could include either overuse of interventions for infants unlikely to benefit from them, underuse of potentially beneficial interventions, or misuse of interventions by inexperienced or unskilled personnel.³³ The increase in pneumothorax rates that we observed in the late 1990s raises the possibility of adverse effects from the overuse or misuse of respiratory interventions and deserves additional study.³⁴ Third, it is possible that the leveling off in mortality resulted from health professionals and families becoming more cautious in extending and continuing intensive care interventions for infants at the extreme limits of viability.³⁵ Our study cannot distinguish among these possibilities.

Although mortality remained constant since 1995 in our Network as a whole, there is still marked variation in both practices and outcomes among individual neonatal intensive care units. For example, in 2000 the interquartile range for unadjusted mortality rates at 352 centers in the Vermont Oxford Network Database for that year was from 11% to 18% and the interquartile range for pneumothorax rates was from 3% to 8% .²⁹ If all units performed at or near the level of those units with the lowest rates, then significant improvements might be realized. We believe that this can be accomplished through organized collaborative learning and benchmarking among multidisciplinary teams from different institutions using a model similar to that reported by O’Connor and colleagues.³⁶ The Vermont Oxford Network is currently fostering this type of multi-institutional learning through the NIC/Q Evidence Based Quality Improvement Collaborative.^37,38

	CONCLUSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION APPENDIX: PARTICIPATING MEMBER... REFERENCES

 
There have been major changes in obstetric and neonatal care during the 1990s. These changes were associated with decreases in mortality and morbidity for VLBW infants during the first half of the decade. However, since 1995, no additional improvements in mortality or morbidity have been seen, ending a decades long trend of improving outcomes for these infants. Additional improvements will require an understanding of the marked variations that still exist in practice and outcomes among different neonatal intensive care units.

	APPENDIX: PARTICIPATING MEMBER HOSPITALS

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Abington Memorial Hospital, Abington, Pennsylvania

Adventist Center for Children, Rockville, Maryland

Aiiku Hospital, Tokyo, Japan

Al Corniche Hospital, Abu Dhabi, United Arab Emirates

Albany Medical Center, Albany, New York

Alta Bates Medical Center, Berkeley, California

Anne Arundel Medical Center, Annapolis, Maryland

Antelope Valley Hospital, Lancaster, California

Arnot Ogden Medical Center, Elmira, New York*

Aultman Hospital, Canton, Ohio*

Aurora Sinai Medical, Milwaukee, Wisconsin

Avera McKennan, Sioux Falls, South Dakota

Ball Memorial Hospital, Muncie, Indiana

Baptist Medical Center, Montgomery, Alabama

Baptist Memorial Hospital for Women, Memphis, Tennessee

Baptist St Anthony’s Health System, Amarillo, Texas

Barbara Bush Children’s at Maine Medical Center, Portland, Maine

Baylor Healthcare System, Dallas, Texas

Baystate Medical Center, Springfield, Massachusetts

Bellevue Hospital/NYU Medical Center, New York, New York

Bellevue Woman’s Hospital, Niskayuna, New York

Benefis Healthcare, Great Falls, Montana

Bethesda Memorial Hospital, Boynton Beach, Florida

Blank Children’s Hospital, Des Moines, Iowa

Bronson Methodist Hospital, Kalamazoo, Michigan

Brookdale Hospital Medical Center, Brooklyn, New York

Broward General Medical Center, Fort Lauderdale, Florida

Bryn Mawr Hospital, Bryn Mawr, Pennsylvania

California Pacific Medical Center, San Francisco, California

Cape Fear Valley Medical Center, Fayetteville, North Carolina

Cardinal Glennon Children’s, St Louis, Missouri

Carelina Neonatology/Wake Medical, Raleigh, North Carolina

Carilion Roanoke Community Hospital, Roanoke, Virginia*

Carle Hospital, Urbana, Illinois

Carolinas Medical Center, Charlotte, North Carolina

Cedars-Sinai Medical Center, Los Angeles, California

Centennial Medical Center, Nashville, Tennessee

Central Dupage Hospital, Winfield, Illinois

Central Mississippi Medical Center, Jackson, Missouri

Centre Hospital University de Sherbrooke, Sherbrooke, Quebec, Canada

Charite-Mitte, Berlin, Germany

Charleston Area Medical Center, Charleston, West Virginia

Children’s Hospitals and Clinics, St Paul, Minnesota

Children’s at Cooper University Medical Center, Camden, New Jersey

Children’s Hospital, Denver, Colorado

Children’s Hospital, San Diego, California

Children’s Hospital at Providence, Anchorage, Alaska

Children’s Hospital Medical Center, Akron, Ohio*

Children’s Hospital Oakland, Oakland, California

Children’s Hospital of Austin, Austin, Texas

Children’s Hospital of Greenville, Greenville, South Carolina*

Children’s Hospital of Iowa, Iowa City, Iowa

Children’s Hospital of the King’s Daughters, Norfolk, Virginia

Children’s Hospital of Wisconsin, Milwaukee, Wisconsin

Children’s Hospital Lee Memorial, Ft Myers, Florida

Children’s Hospitals & Clinics, Minneapolis, Minnesota

Children’s Medical Center, Dayton, Ohio

Children’s Mercy Hospital, Kansas City, Missouri

Children’s of Orange County, Orange, California

Christ Hospital and Medical Center, Oak Lawn, Illinois

Christchurch Women’s Hospital, Christchurch, New Zealand

Christiana Care Health Services, Newark, Delaware

Christus Santa Rosa Health care, San Antonio, Texas

Citrus Valley Inter-Community Campus, Covina, California

City Avenue Allegheny University Hospital, Philadelphia, Pennsylvania

Columbia East Ridge Hospital, Chattanooga, Tennessee

Columbia Hospital for Women, Washington, DC*

Columbia Medical Center of Plano, Dallas, Texas

Columbia Women’s Hospital, Indianapolis, Indiana

Columbus Regional Medical Center, Columbus, Georgia

Community Medical Center, Missoula, Montana

Connecticut Children’s Medical Center, Hartford, Connecticut

Cook Children’s Medical Center, Fort Worth, Texas*

Coral Springs Medical Center, Coral Springs, Florida

Crozer Chester Medical Center, Upland, Pennsylvania

Dameron Hospital, Stockton, California

Danube Hospital SMZ Ost, Vienna, Austria

Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Deaconess Medical Center, Spokane, Washington

Desert Regional Medical Center, Palm Springs, California

DeVos Children’s Spectrum Health, Grand Rapids, Michigan*

Doctor’s Medical Center, Modesto, California

Driscoll Children’s Hospital, Corpus Christi, Texas

East Tennessee Children’s Hospital, Knoxville, Tennessee

East Tennessee State University, Johnson City, Tennessee

Eastern Maine Medical Center, Bangor, Maine

Emanuel Children’s Hospital, Portland, Oregon*

Encino Tarzana Regional Medical Center, Tarzana, California

Evanston Hospital, Evanston, Illinois

Fairview University Medical Center, Minneapolis, Minnesota

Fitzgerald Mercy Medical Center, Darby, Pennsylvania*

Fletcher Allen Health Care, Burlington, Vermont*

Florida Hospital Orlando, Orlando, Florida

Flushing Hospital Medical Center, Flushing, New York

Forrest General Hospital, Hattiesburg, Missouri

Forsyth Memorial Hospital, Winston-Salem, North Carolina

Forum Health Tod Children’s, Youngstown, Ohio

Frankford Torresdale Hospital, Philadelphia, Pennsylvania

Freeman Hospital and Health System, Joplin, Missouri

Gazi University Hospital, Ankara, Turkey

Geisinger Medical Center, Danville, Pennsylvania

Glendale Memorial Hospital & Health Center, Glendale, California

Good Samaritan HCA, San Jose, California

Good Samaritan Hospital, Cincinnati, Ohio*

Good Samaritan Hospital, West Palm Beach, Florida

Good Samaritan Hospital, Los Angeles, California

Grant Medical Center, Columbus, Ohio

Greater Baltimore Medical Center, Baltimore, Maryland*

Gundersen Lutheran, LaCrosse, Wisconsin

Hahnemann University Hospital, Philadelphia, Pennsylvania

Harbor UCLA Medical Center, Torrance, California

Harris Methodist, Fort Worth, Texas*

Hennepin County Medical Center, Minneapolis, Minnesota

Henrico Doctor’s Hospital, Richmond, Virginia*

Henry Ford Hospital, Detroit, Michigan

Holy Cross Hospital, Silver Spring, Maryland

Hospital Auxilio Mutuo, San Juan, Puerto Rico

Hospital Damas, Ponce, Puerto Rico

Hospital for Children and Adolescents, Helsinki, Finland

Hospital of University of Pennsylvania, Philadelphia, Pennsylvania

House of The Good Samaritan, Watertown, New York

Houston Northwest Medical Center, Houston, Texas

Howard County General Hospital, Columbia, Maryland

Huntington Memorial Hospital, Pasadena, California

Huntsville Hospital, Huntsville, Alabama

Hurley Medical Center, Flint, Michigan

Illinois Masonic Medical Center, Chicago, Illinois

Inova Alexandria Hospital, Alexandria, Virginia

Inova Fairfax Hospital for Children, Falls Church, Virginia

IWK Health Centre, Halifax, Nova Scotia, Canada

Jackson Madison County General Hospital, Jackson, Tennessee

Janeway Children’s Hospital Centre, St John, Newfoundland, Canada

Joe DiMaggio Children’s Hospital, Hollywood, Florida*

John Peter Smith Hospital, Fort Worth, Texas

K.K. Women’s & Children’s Hospital, Singapore

Kadlec Medical Center NICU, Richland, Washington

Kaiser Foundation, Los Angeles, California

Kaiser Foundation, Bellflower, California

Kaiser Foundation, San Diego, California

Kaiser Foundation, Woodland Hills, California

Kaiser Foundation of Orange County, Anaheim, California

Kaiser Foundation of West Los Angeles, Los Angeles, California

Kaiser Foundation Hospital, Fontana, California

Kaiser Foundation Hospital, Panorama City, California

Kaiser Foundation/Riverside Medical Center, Riverside, California

Kaiser Permanente, Baldwin Park, California

Kaiser Permanente, Harbor City, California

Kandang Kerbau Hospital, Singapore

Kennedy Memorial Hospital, Stratford, New Jersey

Kinderabteilung KH St Polten, St Polten, Austria

Kinderklinik Glanzing im Wilhelminenspital, Vienna, Austria

Kinderklinik Graz, Graz, Austria

Kosair Children’s Hospital, Louisville, Kentucky

Lehigh Valley Hospital, Allentown, Pennsylvania

Lenox Hill Hospital, New York, New York

Little Company of Mary Hospital, Torrance, California

Loma Linda University Children’s, Loma Linda, California

Lucile Packard Children’s Hospital, Palo Alto, California

Lutheran General Hospital, Park Ridge, Illinois*

Maimonides Medical Center, Brooklyn, New York

Mary Washington Hospital, Fredericksburg, Virginia

Maternidade Dr Alfredo Da Costa, Lisbon, Portugal

McKay Dee Hospital Center, Ogden, Utah*

McLeod Regional Medical Center, Florence, South Carolina

Mease Hospital, Dunedin, Florida*

Medical City Dallas, Dallas, Texas

Medical College of Georgia, Augusta, Georgia

Medical College of Pennsylvania, Philadelphia, Pennsylvania

Medical University of South Carolina, Charleston, South Carolina

Memorial Health University Medical Center, Savannah, Georgia*

Memorial Hospital, South Bend, Indiana

Memorial Hospital at Gulfport, Gulfport, Mississippi

Memorial Hospital West, Pembroke Pines, Florida

Memorial Medical Center, New Orleans, Louisiana

Mercer Medical Center, Trenton, New Jersey

Mercy Children’s Hospital, Toledo, Ohio

Mercy Health Center, Oklahoma City, Oklahoma

Mercy Hospital and Medical Center, Chicago, Illinois*

Mercy Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Mercy Hospital South, Charlotte, North Carolina

Mercy San Juan Hospital, Carmichael, California

Meridia Hillcrest Hospital, Mayfield Heights, Ohio

Meritcare Children’s Hospital, Fargo, North Dakota

Methodist Children’s Hospital, San Antonio, Texas

Methodist Hospital of Indiana, Indianapolis, Indiana

Methodist Hospitals, Inc., Gary, Indiana

Miami Children’s Hospital, Miami, Florida*

Miami Valley Hospital, Dayton, Ohio*

Midwest NeoPed Associates, Oak Brook, Illinois

Miller Children’s Hospital, Long Beach, California

Milton S. Hershey Medical Center, Hershey, Pennsylvania*

Milwaukee Medical Complex, Milwaukee, Wisconsin

Monash Medical Centre, Victoria, Australia

Monmouth Medical Center, Long Branch, New Jersey

Morristown Memorial Hospital, Morristown, New Jersey

Mt. Sinai Hospital, Toronto, Ontario, Canada

Mt. Sinai Hospital Medical Center, Chicago, Illinois

Mt. Sinai Medical Center, Cleveland, Ohio

Munson Medical Center, Traverse City, Michigan

Neonatologiezentrum LKH, Salzburg, Austria

Neonatology Associates, Kingsport, Tennessee

New England Medical Center, Boston, Massachusetts

New Hanover Regional Medical Center, Wilmington, North Carolina

New York Presbyterian Hospital, New York, New York

Newark Beth Israel Medical Center, Newark, New Jersey

Newborn Specialists of Tulsa, Tulsa, Oklahoma

North Memorial Medical Center, Robbinsdale, Minnesota

North Oaks Medical Center, Hammond, Louisiana

Northbay Medical Center, Fairfield, California

Northridge Hospital, Northridge, California

Northside Hospital, Atlanta, Georgia

Northwest Regional Margate, Margate, Florida

Northwestern Memorial, Chicago, Illinois

Novor. Dd. Nsp. Nove Zamky, Nove Zamky, Slovakia

Oakwood Hospital and Medical Center, Dearborn, Michigan

Ochsner Foundation Hospital, New Orleans, Louisiana

Oregon Health & Sciences University, Portland, Oregon

Osaka City General Hospital, Osaka, Japan

Ospedale di Lecco, Lecco, Italy

Ottawa Hospital Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada

Pitt County Memorial Hospital, Greenville, North Carolina

Parkview Memorial Hospital, Fort Wayne, Indiana*

Parkway Regional Medical Center, N. Miami Beach, Florida

Pennsylvania Hospital, Philadelphia, Pennsylvania

Phoenix Children’s Hospital, Phoenix, Arizona

Pinnacle Harrisburg Campus, Harrisburg, Pennsylvania

Presbyterian Hospital, Albuquerque, New Mexico

Presbyterian Hospital of Dallas, Dallas, Texas

Presbyterian St Luke’s Medical Center, Denver, Colorado*

Promina Gwinnet Health, Lawrenceville, Georgia

Provena Covenant Medical Center, Urbana, Illinois

Providence St Joseph Medical Center, Burbank, California

Providence St Vincent Medical Center, Portland, Oregon

Queen Mary Hospital, Hong Kong, China

Rainbow Babies and Children’s Hospital, Cleveland, Ohio

Reading Hospital and Medical Center, Reading, Pennsylvania

Regional Medical Center at Memphis, Memphis, Tennessee

Riverside Hospital, Toledo, Ohio*

Riverside Methodist Hospital, Columbus, Ohio

Rockford Memorial Hospital, Rockford, Illinois

Rogue Valley Medical Center, Medford, Oregon

Rose Medical Center, Denver, Colorado

Rotunda Hospital, Dublin, Ireland

Royal Hobart Hospital, Hobart, Tasmania, Australia

Royal Hospital for Women, Sydney, Australia

Sacred Heart Health System, Pensacola, Florida

Sacred Heart Medical Center, Spokane, Washington

Sacred Heart Medical Center, Eugene, Oregon

San Francisco General Hospital, San Francisco, California

Schumpert Medical Center, Shreveport, Louisiana

Scott and White Hospital, Temple, Texas

Seton Medical Center, Austin, Texas

Sharp Mary Birch Hospital for Women, San Diego, California

Sheridan Children’s, Plantation, Florida*

Sinai Hospital of Baltimore, Baltimore, Maryland

Sisters of Charity, Staten Island, New York

South Fulton Medical Center, East Point, Georgia

Southern New Hampshire Regional Medical Center, Nashua, New Hampshire

Southern Regional Medical Center, Riverdale, Georgia

Sparrow Hospital, Lansing, Michigan*

St Agnes Hospital, Baltimore, Maryland*

St Barnabas Medical Center, Livingston, New Jersey

St Charles Medical Center, Bend, Oregon

St Cloud Hospital, St Cloud, Minnesota

St Elizabeth Hospital Center, Youngstown, Ohio

St Elizabeth Regional Medical Center, Lincoln, Nebraska

St Elizabeth’s Medical Center, Boston, Massachusetts

St Francis Hospital, Tulsa, Oklahoma*

St Francis Hospital, Hartford, Connecticut*

St Francis Medical Center, Peoria, Illinois

St Francis Medical Center, Lynwood, California

St John Hospital and Medical Center, Detroit, Michigan*

St John’s Hospital Springfield, Springfield, IL

St John’s Mercy Medical Center, St Louis, MO

St John’s Regional Medical Center, Oxnard, CA

St Joseph Hospital, Denver, CO*

St Joseph Hospital, Houston, TX

St Joseph Hospital and Medical Center, Paterson, NJ

St Joseph Hospital Marshfield Clinic, Marshfield, Wisconsin*

St Joseph’s Health Center, Syracuse, New York

St Joseph’s Hospital, Milwaukee, Wisconsin

St Joseph’s Hospital and Medical Center, Phoenix, Arizona

St Louis Regional Medical Center, St Louis, Missouri

St Luke’s Hospital, Bethlehem, Pennsylvania*

St Luke’s Hospital, Kansas City, Missouri

St Luke’s Hospital, Racine, Wisconsin

St Luke’s Memorial Hospital, Utica, New York

St Lukes Regional Medical Center, Boise, Idaho

St Mary Medical Center, Long Beach, California

St Mary’s Hospital, West Palm Beach, Florida

St Mary’s Hospital and Medical Center, Grand Junction, Colorado

St Mary’s Hospital Medical Center, Madison, Wisconsin

St Mary’s Hospital-Milwaukee, Milwaukee, Wisconsin

St Mary’s Medical Center, Evansville, Indiana

St Mary’s Duluth Clinic Health Systems, Duluth, Minnesota

St Paul Medical Center, Dallas, Texas

St Peter’s Hospital, Albany, New York

St Peter’s Medical Center, New Brunswick, New Jersey

St Vincent Hospital, Indianapolis, Indiana

St Vincent Hospital, Green Bay, Wisconsin

St Vincent Hospital and Health Center, Billings, Montana

Stamford Hospital, Stamford, Connecticut

Sunnybrook and Women’s College, Toronto, Ontario, Canada*

Sunrise Children’s Hospital, Las Vegas, Nevada

Sutter Memorial Hospital, Sacramento, California

Swedish American Hospital, Rockford, Illinois

Swedish Medical Center, Englewood, Colorado

T.C. Thompson Children’s Hospital, Chattanooga, Tennessee

Tacoma General Hospital, Tacoma, Washington

Tallahassee Memorial Regional, Tallahassee, Florida

Tampa General, Tampa, Florida

Temple University Hospital, Philadelphia, Pennsylvania

Texas Tech University Health Science Center, Amarillo, Texas

The Brooklyn Hospital Center, Brooklyn, New York

Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

Tisch Hospital NYU Medical Center, New York, New York

Tokyo Women’s Medical College, Tokyo, Japan

Toledo Hospital, Toledo, Ohio

Truman Medical Center, Kansas City, Missouri

Tulane Medical Center, New Orleans, Louisiana

University of California Irvine Medical Center, Orange, California

University of California Davis Medical Center, Sacramento, California

University of California San Diego Medical Center, San Diego, California

University of California San Francisco Medical Center, San Francisco, California

University of Colorado Health Sciences Center, Denver, Colorado

University of Massachusetts Memorial Health Care, Worcester, Massachusetts*

University Hospital Motol, Prague, Czech Republic

University Hospital Vienna - AKH, Vienna, Austria

University Kebangsaan Malaysia, Kuala Lumpur, Malaysia

University Klinik F. Kinder, Innsbruck, Austria

University Medical Center, Las Vegas, Nevada

University of Chicago, Chicago, Illinois

University of Illinois at Chicago, Chicago, Illinois

University of Kentucky Children’s Hospital, Lexington, Kentucky

University of Louisville Hospital, Louisville, Kentucky

University of Michigan Holden NICU, Ann Arbor, Michigan

University of Puerto Rico Hospital NICU, San Juan, Puerto Rico

University of Tennessee Medical Center at Knoxville, Knoxville, Tennessee

University of Texas Medical Branch, Galveston, Texas

UPMC Lee Regional, Johnstown, Pennsylvania

Utah Valley Regional Medical Center, Provo, Utah

Valley Children’s Hospital, Madera, California

Vassar Brothers Hospital, Poughkeepsie, New York

Ventura County Medical Center, Ventura, California

Via Christi/St Francis Campus, Wichita, Kansas

Virginia Beach General Hospital, Virginia Beach, Virginia

Waikato Hospital, Hamilton, New Zealand

Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina

Waukesha Memorial Hospital, Waukesha, Wisconsin

Weiler Hospital Montefiore, Bronx, New York

Wellstar Kennestone Hospital, Marietta, Georgia

Wesley Medical Center, Wichita, Kansas*

West Boca Medical Center, Boca Raton, Florida

Western Medical Center, Santa Ana, California

Western Pennsylvania Hospital, Pittsburgh, Pennsylvania

Woman’s Hospital Baton Rouge, Baton Rouge, Louisianna

Women’s and Children’s Hospital, Lafayette, Louisiana

Women’s Hospital of Greensboro, Greensboro, North Carolina

Woodhull Medical Center, Brooklyn, New York

Yakima Valley Memorial Hospital, Yakima, Washington

York Hospital, York, Pennsylvania

*Participated in the Vermont Oxford Network Database 1991 to 1999

	ACKNOWLEDGMENTS

 
We thank the team members at participating hospitals for their dedication to improving the quality and safety of medical care for newborn infants and their families and for their voluntary participation in the Vermont Oxford Network Database that made this research possible.

	FOOTNOTES

 
Received for publication Mar 20, 2002; Accepted Apr 9, 2002.

Reprint requests to A. Lynn Stillman, Vermont Oxford Network, 33 Kilburn St, Burlington, VT 05401. E-mail: horbar{at}vtoxford.org

Dr Horbar is the Chief Executive and Scientific Officer of the Vermont Oxford Network. Dr Soll is the Director of Clinical Trials of the Vermont Oxford Network. Mr Carpenter is the Director of Technical Operations of the Vermont Oxford Network. Drs Fanaroff, Kilpatrick, LaCorte, and Phibbs are members of the Vermont Oxford Network Database Advisory Committee.

Presented in part at the Pediatric Academic Societies Annual Meeting, Baltimore, MD, April 29, 2001.

	REFERENCES

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION CONCLUSION APPENDIX: PARTICIPATING MEMBER... REFERENCES

 

1. NIH Consensus Development Panel on the Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes. Effect of corticosteroids for fetal maturation on perinatal outcomes. JAMA.1995; 273 :413 –418[Abstract]
2. Jobe AH. Pulmonary surfactant therapy. N Engl J Med.1993; 328 :861 –868[Free Full Text]
3. Halliday HL, Ehrenkrantz RA. Early postnatal (<96 hours) corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev.2000; 2 :CD001146
4. Greenough A, Milner AD, Dimitriou G. Synchronized mechanical ventilation for respiratory support in newborn infants. Cochrane Database Syst Rev.2000; 2 :CD000456
5. Henderson-Smart DJ, Bhuta T, Cools F, Offringa M. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev.2000; 2 :CD000104
6. Wung JT, Driscoll J, James S. Treatment of Neonatal RDS [videotape]. New York: Babies Hospital, Columbia University; 1986
7. McCormick MC, Richardson DK. Access to neonatal intensive care. Future Child.1995; 5 :162 –175[CrossRef][ISI][Medline]
8. Paneth NS. The problem of low birth weight. Future Child.1995; 5 :19 –34[CrossRef][ISI][Medline]
9. Richardson DK, Gray JE, Gortmaker SL, et al. Declining severity adjusted mortality: evidence of improving neonatal care. Pediatrics.1998; 102 :893 –899[Abstract/Free Full Text]
10. Singh GK, Yu SM. Infant mortality in the United States: trends, differentials, and projections, 1950 through 2010. Am J Public Health.1995; 85 :957 –964[Abstract/Free Full Text]
11. Horbar JD. The Vermont Oxford Network: evidence-based quality improvement for neonatology. Pediatrics.1999; 103(suppl) :350 –359
12. The Vermont-Oxford Trials Network: very low birth weight outcomes for 1990. Investigators of the Vermont-Oxford Trials Network Database Project. Pediatrics.1993; 91 :540 –545[Abstract/Free Full Text]
13. Vermont Oxford Network Database Manual of Operations. Release 5.0. Burlington, VT: Vermont Oxford Network; 2000
14. Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika.1986; 73 :13 –22[Abstract/Free Full Text]
15. Martin JA, Hamilton BE, Ventura SJ. Births: preliminary data for 2000. National Vital Statistics Reports.2001; 49 :1 –20
16. Hack M, Horbar JD, Malloy MH, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Network. Pediatrics.1991; 87 :587 –597[Abstract/Free Full Text]
17. Hack M, Wright LL, Shankaran S, et al. Very-low-birth-weight outcomes of the National Institute of Child Health and Human Development Neonatal Network, November 1989 to October 1990. Am J Obstet Gynecol.1995; 172 :457 –464[CrossRef][ISI][Medline]
18. Stevenson DK, Wright LL, Lemons JA, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1993 through December 1994. Am J Obstet Gynecol.1998; 179 :1632 –1639[CrossRef][ISI][Medline]
19. Lemons JA, Bauer CR, Oh W, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 through December1996. Pediatrics.2001; 107(1) . Available at: www.pediatrics.org/cgi/content/full/107/1/e1
20. Crowley PA. Antenatal corticosteroid therapy: a meta-analysis of the randomized trials, 1972 to 1994. Am J Obstet Gynecol.1995; 173 :322 –335[CrossRef][ISI][Medline]
21. Soll RF, Morley CJ. Prophylactic versus selective use of surfactant for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev.2000; 2 :CD000510
22. Soll RF. Multiple versus single dose natural surfactant extract for severe neonatal respiratory distress syndrome. Cochrane Database Syst Rev.2000; 2 :CD000141
23. Horbar JD, Wright EC, Onstadt L. Decreasing mortality associated with the introduction of surfactant therapy: an observational study of neonates weighing 601 to 1300 grams at birth. Pediatrics.1993; 92 :191 –196[Abstract/Free Full Text]
24. Schwartz RM, Luby AM, Scanlon JW, Kellogg RJ. Effect of surfactant on morbidity, mortality, and resource use in newborn infants weighing 500 to 1500 g. N Engl J Med.1994; 330 :1476 –1480[Abstract/Free Full Text]
25. Horbar JH, Carpenter J, Soll RF, et al. Trend to earlier initiation of surfactant therapy from 1998 to 2000 [abstract]. Pediatr Res.2002; 51 :407A
26. Jobe AH, Mitchell BR, Gunkel JH. Beneficial effects of the combined use of prenatal corticosteroids and postnatal surfactant on preterm infants. Am J Obstet Gynecol.1993; 168 :508 –513[ISI][Medline]
27. Ventura SJ, Martin JA, Curtin SC, Menacker P, Hamilton BE. Births: final data for 1999. Natl Vital Stat Rep.2001; 49 :1 –100[Medline]
28. Donovan EF, Ehrenkranz RA, Shankaran S, et al. Outcomes of very low birth weight twins cared for in the National Institute of Child Health and Human Development Neonatal Research Network’s intensive care units. Am J Obstet Gynecol.1998; 179 :742 –749[CrossRef][ISI][Medline]
29. Horbar JD, ed. Vermont Oxford Network 2000 Database Summary. Burlington, VT: Vermont Oxford Network; 2001
30. Thebaud B, Lacaze-Masmonteil T, Watterberg K. Postnatal glucocorticoids in very preterm infants: "the good, the bad, and the ugly"? Pediatrics.2001; 107 :413 –415[Free Full Text]
31. Hack M, Fanaroff AA. Outcomes of children of extremely low birth weight and gestational age in the 1990’s. Early Hum Dev.1999; 53 :193 –218[CrossRef][ISI][Medline]
32. Silverman WA. Unnatural selection. Pediatrics.2001; 107 :1421 –1422[Free Full Text]
33. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine Roundtable on Health Care Quality. JAMA.1998; 280 :1000 –1005[Abstract/Free Full Text]
34. Subramaniam P, Henderson-Smart DJ, Davis PG. Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants. Cochrane Database Syst Rev.2000; 2 :CD001243
35. Bottoms SF, Paul RH, Iams JD, et al. Obstetric determinants of neonatal survival: influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. Am J Obstet Gynecol.1997; 176 :960 –966[CrossRef][ISI][Medline]
36. O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. The Northern New England Cardiovascular Disease Study Group. JAMA.1996; 275 :841 –846[Abstract]
37. Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal intensive care. Pediatrics.2001; 107 :14 –22[Abstract/Free Full Text]
38. Rogowski JA, Horbar JD, Plsek PE, et al. Economic implications of neonatal intensive care unit collaborative quality improvement. Pediatrics.2001; 107 :23 –29[Abstract/Free Full Text]

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