Trends in Mortality and Morbidity for Very Low Birth Weight Infants, 1991–1999
* 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
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONAPPENDIX: PARTICIPATING MEMBER...REFERENCES |
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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
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONAPPENDIX: PARTICIPATING MEMBER...REFERENCES |
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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
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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.
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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.
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Significant changes in obstetric practices were observed over the study period at both groups of institutions with increases in proportion of infants whose mothers received prenatal care and the proportion delivered by cesarean section. The most notable change was the increase in the use of antenatal corticosteroid therapy from 23.8% in 1991 to 71.6% in 1999. The changes in prenatal care, antenatal steroid administration, and cesarean delivery remained statistically significant in both sets of hospitals after adjusting for changes in infant characteristics.
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.
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The adjusted odds ratios associated with yearly changes in mortality and morbidity are shown for the entire 9-year period and separately for the 2 time periods 1991 to 1995 and 1995 to 1999 in Table 3. The risks for mortality, pneumothorax, intraventricular hemorrhage (IVH; any grade), and severe IVH (grades 3 and 4) decreased from 1991 to 1999 in both sets of hospitals. During the period 1991 to 1995, the risks for mortality and pneumothorax decreased significantly at both groups of hospitals, whereas from 1995 to 1999, the point estimates of the odds ratios indicate increasing risks with time although the findings are statistically significant only in the case of pneumothorax. The data for IVH and severe IVH are more difficult to interpret with the only statistically significant results being a reduction in risk over time in severe IVH from 1991 to 1995 at the total group of 362 hospitals and in any IVH at the subgroup of 39 hospitals.
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The trends in mortality for all infants are shown by birth weight category in Fig 2. Mortality declined in all birth weight categories from 1991 to 1995 with no evidence of additional decline thereafter. For infants weighing 501 to 750 g, mortality decreased from 53% in 1991 to 42% in 1995; it then remained at 42% to 43% from 1996 to 1998 with an increase to 45% in 1999.
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Figure 3 shows the rates of pneumothorax by birth weight category for infants at all 362 institutions. For infants weighing 501 to 750 g, pneumothorax rates decreased from
16% in 1991 and 1992 to the range of 10% to 11% in 1994 to 1996 and then increased to over 14% in 1999. The data for the other birth weight categories showed decreases from 1991 to 1996 with small increases thereafter.
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Figure 4 shows the rates of IVH by birth weight category at all 362 institutions. For infants weighing 501 to 750 g, the rate of IVH decreased from the range of 46% to 49% in 1991 to 1993 to the range of 41% to 42% in 1997 to 1999. Small decreases before 1995 were seen for infants weighing 751 to 1000 g and 1001 to 1500 g.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONAPPENDIX: PARTICIPATING MEMBER...REFERENCES |
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We observed major changes in both obstetric and neonatal care for VLBW infants during the 1990s. These changes were associated with significant decreases in mortality and pneumothorax between 1991 and 1995. From 1995 to 1999, mortality remained relatively constant, whereas pneumothorax rates actually increased. IVH and severe IVH decreased significantly over the 9-year study period, but the specific trends before and after 1995 for these outcomes are less certain.
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
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONAPPENDIX: PARTICIPATING MEMBER...REFERENCES |
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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.
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APPENDIX: PARTICIPATING MEMBER HOSPITALS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONAPPENDIX: PARTICIPATING MEMBER...REFERENCES |
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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
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ACKNOWLEDGMENTS |
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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.
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FOOTNOTES |
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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.
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L. Castro, K. Yolton, B. Haberman, N. Roberto, N. I. Hansen, N. Ambalavanan, B. R. Vohr, and E. F. Donovan Bias in Reported Neurodevelopmental Outcomes Among Extremely Low Birth Weight Survivors Pediatrics, August 1, 2004; 114(2): 404 - 410. [Abstract] [Full Text] [PDF]
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J. F. Lucey, C. A. Rowan, P. Shiono, A. R. Wilkinson, S. Kilpatrick, N. R. Payne, J. Horbar, J. Carpenter, J. Rogowski, and R. F. Soll Fetal Infants: The Fate of 4172 Infants With Birth Weights of 401 to 500 Grams--The Vermont Oxford Network Experience (1996-2000) Pediatrics, June 1, 2004; 113(6): 1559 - 1566. [Abstract] [Full Text] [PDF]
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W. Meadow, G. Lee, K. Lin, and J. Lantos Changes in Mortality for Extremely Low Birth Weight Infants in the 1990s: Implications for Treatment Decisions and Resource Use Pediatrics, May 1, 2004; 113(5): 1223 - 1229. [Abstract] [Full Text] [PDF]
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C. H. Cole, K. W. Wright, W. Tarnow-Mordi, and D. L. Phelps Resolving Our Uncertainty About Oxygen Therapy Pediatrics, December 1, 2003; 112(6): 1415 - 1419. [Full Text] [PDF]
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B. M. Stefanescu, W. P. Murphy, B. J. Hansell, M. Fuloria, T. M. Morgan, and J. L. Aschner A Randomized, Controlled Trial Comparing Two Different Continuous Positive Airway Pressure Systems for the Successful Extubation of Extremely Low Birth Weight Infants Pediatrics, November 1, 2003; 112(5): 1031 - 1038. [Abstract] [Full Text] [PDF]
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R. H. Clark, J. Cifuentes, J. Bronstein, C. S. Phibbs, S. K. Schmitt, R. H. Phibbs, and W. A. Carlo Mortality in Low Birth Weight Infants According to Level of Neonatal Care at Hospital of Birth Pediatrics, July 1, 2003; 112(1): 203 - 204. [Full Text] [PDF]
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P. Anderson and L. W. Doyle Neurobehavioral Outcomes of School-age Children Born Extremely Low Birth Weight or Very Preterm in the 1990s JAMA, June 25, 2003; 289(24): 3264 - 3272. [Abstract] [Full Text] [PDF]
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 J. Jaubert, J. Cheng, and J. A. Segre Ectopic expression of Kruppel like factor 4 (Klf4) accelerates formation of the epidermal permeability barrier Development, June 15, 2003; 130(12): 2767 - 2777. [Abstract] [Full Text] [PDF]
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L. R. Blackmon The Role of the Hospital of Birth on Survival of Extremely Low-birthweight, Extremely Preterm Infants NeoReviews, June 1, 2003; 4(6): e147 - 152. [Full Text] [PDF]
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W. Meadow and J. Lantos Ethics at the Limit of Viability: A Premie's Progress NeoReviews, June 1, 2003; 4(6): e157 - 162. [Full Text] [PDF]
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A. G. S. Philip and G. C. Liggins Historical Perspectives: The Underpinnings of Neonatal/Perinatal Medicine: Antepartum Glucocorticoid Treatment NeoReviews, November 1, 2002; 3(11): e227 - 228. [Full Text] [PDF]
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