Telemedicine Collaboration Lowers Infant Mortality
Telemedicine Collaboration Lowers Infant Mortality
In 2009, the Centers for Medicare and Medicaid Services, a component of the United States Department of Health and Human Services, partnered with the University of Arkansas for Medical Sciences (UAMS) to initiate the TOUCH project. Nine obstetric and nursery sites across the state (Figure 1), chosen because of high-birth volume, were designated as TM hospitals, and included Jefferson Regional Medical Center (Pine Bluff, AR, USA), Mercy Medical Center (Rogers, AR, USA), National Park Medical Center (Hot Springs, AR, USA), Ouachita County Medical Center (Camden, AR, USA), St Bernard's Regional Medical Center (Jonesboro, AR, USA), St Edward Mercy Medical Center (Fort Smith, AR, USA), CHRISTUS St Michael Health System (Texarkana, TX, USA), Washington Regional Medical Center (Fayetteville, AR, USA), and Willow Creek Women's Hospital (Johnson, AR, USA). Five of the 9 hospitals did not offer specialized newborn care and were the targeted hospitals.
(Enlarge Image)
Figure 1.
State map of participating TOUCH hospitals; asterisk (*) denotes nurseries with a NICU (CHRISTUS St Michael's gained NICU designation approximately halway through the project). Jefferson Regional Hospital-Pine Bluff, Jefferson Country; Mercy Medical Centre-Rogers, Benton Country; National park Medical Center-Hot Springs, Garland country; Ouachita country medical center-Camden, Ouachita Country; St Bernard's Medical Center-Jonesboro, Craighead Country; St Edwards-Fort Smith, Sebastian Country*; CHRISTUS St Michael's-Texarkana, Miller Country*; Washington Regional Medical Center-Fayetteville, Washington Country*; Willow Creek Women's Center-Johnson, Washington Country*.
In the initial project phase, Tandberg (Atlanta, GA, USA) TM codec camera carts and clinical equipment were purchased. The units were placed in the nine TM hospitals with the co-operative effort of UAMS video support personnel working with nurse managers or other administrative officials at the outlying hospitals. Connectivity was established using T1 lines capable of a data transfer speed of 1.5 megabits per second. UAMS outreach staff, including a neonatologist, an obstetrician and registered nurses, traveled to the outlying sites to perform initial in-service training on the use of TM technology. The sites were educated on the stepwise process of contacting the well-established obstetric ANGELS Call Center and the neonatal Angel One Transport Team (Arkansas Children's Hospital transport team) in order to facilitate consultations and transports of obstetric and neonatal patients. The ANGELS Call Center and Angel One Transport Team are staffed with registered nurses, who field calls from referring physicians. Test calls between providers at TM hospitals and those at UAMS were conducted before initiating the program to ensure the TM connection was in place and that the video quality was acceptable. TM support was provided by (1) twice weekly TM census rounds provided by obstetrics faculty at UAMS, (2) continuous (24/7) TM obstetrics consultation through the ANGELS Call Center, (3) three times weekly TM neonatal rounds conducted with neonatology faculty at UAMS, (4) continuous (24/7) TM neonatology consultation, (5) education in the form of peer-reviewed treatment guidelines based on current standards of care (available at http://www.uams.edu/angels), (6) three times weekly interactive video education conferences for obstetrics and pediatrics and (7) ongoing TM social support, such as visually introducing caregivers from the perinatal center to parents and visualization of their infants following delivery. TM census rounds consisted of participating hospital staff communicating their census, availability for back transport of UAMS or Arkansas Children's Hospital patients, anticipated problem deliveries and need for consultation. Rounds began at 0815 hours on Monday, Wednesday and Friday and lasted 15 to 30 min. Staff obstetricians, neonatologists and referring physicians were able to discuss patients of interest, view patients at the time of consultation and collaborate on case management, including evaluation of patients for transfer to a higher level of care. Educational opportunities included 2 weekly obstetrical teleconferences, obstetrical grand rounds and high-risk obstetrical case presentations, and a weekly interactive pediatric lecture on neonatal and pediatric topics (Peds PLACE). The UAMS Institutional Review Board approved this study before program initiation and data collection.
This was a prospective study, with pre- and post-assessment. The program was established and the study conducted over a 13-month period from 1 March 2009 through 31 March 2010. The first 4 months (1 March to 30 June 2009) were dedicated to establishing connectivity with the community hospitals, and were designated as a training period. The program was in full operation for the remaining 9 months. Following the program completion, Medicaid data for VLBW neonates, as indicated by their International Classification of Diseases, Book 9 (ICD-9) diagnosis codes on hospital and physician claims, were obtained for the 9-month study period and for the 9-month period before initiation of the TM program (1 July 2008 to 31 March 2009). The methodology for matching birth and death certificates with claims data for Medicaid has been described previously. Mortality and morbidity were assigned to the birth hospitals for these neonates, which were determined from claims data and were categorized as being a TM hospital—NICU, TM hospital—non-NICU, non-TM hospital—NICU and non-TM hospital—non-NICU. Mortality and morbidity for every patient that was transferred was assigned back to the birth hospital regardless of transfer. Patients from UAMS were analyzed as a separate study group as it was the central TM site. Our primary goal was to utilize TM collaboration to decrease the number of VLBW deliveries at TM hospitals without NICUs. We hypothesized that the number of VLBW neonates delivered in hospitals without a NICU would decrease, thereby improving perinatal regionalization and mortality. Additionally, tracking VLBW deliveries would be an objective way to assess appropriate referrals. Secondary outcome measures included evaluation of changes in morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis and grades 3 and 4 intraventricular hemorrhage, IVH).
To determine which hospital, if any, the VLBW neonate was transferred to after delivery, the earliest Medicaid claim for a hospital with an admission date on the same day as the discharge date of the delivery hospital was found. After a transfer hospital was found, the TM and NICU status were determined using the same method that was used for the delivery hospitals.
Once the VLBW neonates were identified, we determined whether their mothers were also in the Medicaid system by querying a Medicaid table that links mothers and neonates based on various demographic characteristics. If a match was found, the mother's identifier was linked to the VLBW neonate's identifier.
Claims for the VLBW neonates during their first 3 months of life were retrieved from the Medicaid database. Fields such as the recipient's county of residence, dates of service, primary and secondary diagnoses, procedure codes and paid amount were extracted from these claims. Additionally, for those mothers to whom neonates were matched, delivery claims with a date of service within 2 days of the neonate's date of birth were identified along with the fields for the neonate's claims.
Death before hospital discharge was used to assess hospital mortality in Table 2. Statewide infant mortality, death before 1 year of age, was assessed because of the concern that this program could be shifting mortality from lower to higher level centers or that neonates were not surviving after discharge. These data were obtained from the Arkansas Department of Health for Arkansas deliveries, and χ analysis was used to compare infant mortality rates 9 months immediately before (1 Oct 2008 through 30 June 2009) and after (1 July 2009 through 31 March 2010) TM intervention.
Claims data were evaluated using a generalized linear model with site, time and a site by time interaction term. This model allows for straightforward statistical tests using for the effect of time at each site. We compared delivery site of VLBW neonates, mortality and morbidity across hospital groups, and pre- and post-TM. Discharge status, including transfer and death, and length of stay were also evaluated. Secondary outcomes were identified based on ICD-9 codes recorded on patient Medicaid claims. We compared pre- and post-TM sites of delivery for birth place, mortality and morbidity across hospital groups. Discharge status, including transfer, death and length of stay were also evaluated.
Each TM codec camera cart (complete with integrated speakers, installation, training, and 3 years support) was purchased at a cost of $17 500. The total cost of network connectivity was $250 to $800 per nursery, depending on the internet provider used by each facility and depending on the existing internet connectivity and the individual information technology needs of each nursery.
Methods
TM Outreach Utilizing Collaborative Health-care (TOUCH) Program
In 2009, the Centers for Medicare and Medicaid Services, a component of the United States Department of Health and Human Services, partnered with the University of Arkansas for Medical Sciences (UAMS) to initiate the TOUCH project. Nine obstetric and nursery sites across the state (Figure 1), chosen because of high-birth volume, were designated as TM hospitals, and included Jefferson Regional Medical Center (Pine Bluff, AR, USA), Mercy Medical Center (Rogers, AR, USA), National Park Medical Center (Hot Springs, AR, USA), Ouachita County Medical Center (Camden, AR, USA), St Bernard's Regional Medical Center (Jonesboro, AR, USA), St Edward Mercy Medical Center (Fort Smith, AR, USA), CHRISTUS St Michael Health System (Texarkana, TX, USA), Washington Regional Medical Center (Fayetteville, AR, USA), and Willow Creek Women's Hospital (Johnson, AR, USA). Five of the 9 hospitals did not offer specialized newborn care and were the targeted hospitals.
(Enlarge Image)
Figure 1.
State map of participating TOUCH hospitals; asterisk (*) denotes nurseries with a NICU (CHRISTUS St Michael's gained NICU designation approximately halway through the project). Jefferson Regional Hospital-Pine Bluff, Jefferson Country; Mercy Medical Centre-Rogers, Benton Country; National park Medical Center-Hot Springs, Garland country; Ouachita country medical center-Camden, Ouachita Country; St Bernard's Medical Center-Jonesboro, Craighead Country; St Edwards-Fort Smith, Sebastian Country*; CHRISTUS St Michael's-Texarkana, Miller Country*; Washington Regional Medical Center-Fayetteville, Washington Country*; Willow Creek Women's Center-Johnson, Washington Country*.
In the initial project phase, Tandberg (Atlanta, GA, USA) TM codec camera carts and clinical equipment were purchased. The units were placed in the nine TM hospitals with the co-operative effort of UAMS video support personnel working with nurse managers or other administrative officials at the outlying hospitals. Connectivity was established using T1 lines capable of a data transfer speed of 1.5 megabits per second. UAMS outreach staff, including a neonatologist, an obstetrician and registered nurses, traveled to the outlying sites to perform initial in-service training on the use of TM technology. The sites were educated on the stepwise process of contacting the well-established obstetric ANGELS Call Center and the neonatal Angel One Transport Team (Arkansas Children's Hospital transport team) in order to facilitate consultations and transports of obstetric and neonatal patients. The ANGELS Call Center and Angel One Transport Team are staffed with registered nurses, who field calls from referring physicians. Test calls between providers at TM hospitals and those at UAMS were conducted before initiating the program to ensure the TM connection was in place and that the video quality was acceptable. TM support was provided by (1) twice weekly TM census rounds provided by obstetrics faculty at UAMS, (2) continuous (24/7) TM obstetrics consultation through the ANGELS Call Center, (3) three times weekly TM neonatal rounds conducted with neonatology faculty at UAMS, (4) continuous (24/7) TM neonatology consultation, (5) education in the form of peer-reviewed treatment guidelines based on current standards of care (available at http://www.uams.edu/angels), (6) three times weekly interactive video education conferences for obstetrics and pediatrics and (7) ongoing TM social support, such as visually introducing caregivers from the perinatal center to parents and visualization of their infants following delivery. TM census rounds consisted of participating hospital staff communicating their census, availability for back transport of UAMS or Arkansas Children's Hospital patients, anticipated problem deliveries and need for consultation. Rounds began at 0815 hours on Monday, Wednesday and Friday and lasted 15 to 30 min. Staff obstetricians, neonatologists and referring physicians were able to discuss patients of interest, view patients at the time of consultation and collaborate on case management, including evaluation of patients for transfer to a higher level of care. Educational opportunities included 2 weekly obstetrical teleconferences, obstetrical grand rounds and high-risk obstetrical case presentations, and a weekly interactive pediatric lecture on neonatal and pediatric topics (Peds PLACE). The UAMS Institutional Review Board approved this study before program initiation and data collection.
Study Design
This was a prospective study, with pre- and post-assessment. The program was established and the study conducted over a 13-month period from 1 March 2009 through 31 March 2010. The first 4 months (1 March to 30 June 2009) were dedicated to establishing connectivity with the community hospitals, and were designated as a training period. The program was in full operation for the remaining 9 months. Following the program completion, Medicaid data for VLBW neonates, as indicated by their International Classification of Diseases, Book 9 (ICD-9) diagnosis codes on hospital and physician claims, were obtained for the 9-month study period and for the 9-month period before initiation of the TM program (1 July 2008 to 31 March 2009). The methodology for matching birth and death certificates with claims data for Medicaid has been described previously. Mortality and morbidity were assigned to the birth hospitals for these neonates, which were determined from claims data and were categorized as being a TM hospital—NICU, TM hospital—non-NICU, non-TM hospital—NICU and non-TM hospital—non-NICU. Mortality and morbidity for every patient that was transferred was assigned back to the birth hospital regardless of transfer. Patients from UAMS were analyzed as a separate study group as it was the central TM site. Our primary goal was to utilize TM collaboration to decrease the number of VLBW deliveries at TM hospitals without NICUs. We hypothesized that the number of VLBW neonates delivered in hospitals without a NICU would decrease, thereby improving perinatal regionalization and mortality. Additionally, tracking VLBW deliveries would be an objective way to assess appropriate referrals. Secondary outcome measures included evaluation of changes in morbidity (bronchopulmonary dysplasia, necrotizing enterocolitis and grades 3 and 4 intraventricular hemorrhage, IVH).
To determine which hospital, if any, the VLBW neonate was transferred to after delivery, the earliest Medicaid claim for a hospital with an admission date on the same day as the discharge date of the delivery hospital was found. After a transfer hospital was found, the TM and NICU status were determined using the same method that was used for the delivery hospitals.
Once the VLBW neonates were identified, we determined whether their mothers were also in the Medicaid system by querying a Medicaid table that links mothers and neonates based on various demographic characteristics. If a match was found, the mother's identifier was linked to the VLBW neonate's identifier.
Claims for the VLBW neonates during their first 3 months of life were retrieved from the Medicaid database. Fields such as the recipient's county of residence, dates of service, primary and secondary diagnoses, procedure codes and paid amount were extracted from these claims. Additionally, for those mothers to whom neonates were matched, delivery claims with a date of service within 2 days of the neonate's date of birth were identified along with the fields for the neonate's claims.
Mortality
Death before hospital discharge was used to assess hospital mortality in Table 2. Statewide infant mortality, death before 1 year of age, was assessed because of the concern that this program could be shifting mortality from lower to higher level centers or that neonates were not surviving after discharge. These data were obtained from the Arkansas Department of Health for Arkansas deliveries, and χ analysis was used to compare infant mortality rates 9 months immediately before (1 Oct 2008 through 30 June 2009) and after (1 July 2009 through 31 March 2010) TM intervention.
Statistical Plan
Claims data were evaluated using a generalized linear model with site, time and a site by time interaction term. This model allows for straightforward statistical tests using for the effect of time at each site. We compared delivery site of VLBW neonates, mortality and morbidity across hospital groups, and pre- and post-TM. Discharge status, including transfer and death, and length of stay were also evaluated. Secondary outcomes were identified based on ICD-9 codes recorded on patient Medicaid claims. We compared pre- and post-TM sites of delivery for birth place, mortality and morbidity across hospital groups. Discharge status, including transfer, death and length of stay were also evaluated.
Cost
Each TM codec camera cart (complete with integrated speakers, installation, training, and 3 years support) was purchased at a cost of $17 500. The total cost of network connectivity was $250 to $800 per nursery, depending on the internet provider used by each facility and depending on the existing internet connectivity and the individual information technology needs of each nursery.
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