CTN Telemedicine Core Facility: This
facility was set up in 2006 (P20RR020146-03), and expanded with two
supplements, including a ARRA supplement (3P20RR020146-05S1). This Core includes real-time teleconferencing and
diagnostic quality imaging equipment for 20 rural hospitals and a
central Mediasite facility. Weekly telemedicine conferences on
perinatology allow our community of health care personnel, including
physicians, nurses and therapists, to participate live, to gain
continuing medical education (CME) credit, and to help develop
therapeutic and other guidelines.
The Core runs the Pediatric Physician Learning and Collaborative
Education (Peds PLACE) program.
Peds PLACE involves a weekly educational teleconference in
real-time, followed by a consultation hour, across up to 25 neonatal
intensive care units or delivery facilities that account for >95% of all
births in the state (total ~40,000 per year).
Consensus guidelines are developed in collaboration with physicians
across the state and these are posted in the website for future
reference and education.
Telenursery is the research arm of PedsPLACE that seeks to
decrease mortality, especially among low birth weight babies.
Since the start of PedsPLACE in 2006, the mortality rate in live births
has significantly decreased from 8.5 per thousand to 7 per thousand.
This amounts to saving ~60 babies per year, every year from now on.
|A second program links 9 existing Emergency Department sites
with 6 new ones in a program called Emergency Department
Physician Learning and Collaborative Education (EDs PLACE)
program of the Community Based Research and Education (CoBRE)
Core Facility of the Center for Translational Neuroscience (CTN).
Our 6 units were added to the existing network of AR SAVES.
Community Based Research and
Education (COBRE) Core Facility
view our latest poster from our Community Based Research and Education (CoBRE)
One definition of translational research is the
application of basic science findings to the bedside. However, in this
context, we define translational neuroscience as using biomedical
knowledge and research to solve real problems in the community. In
this case, we address children's health issues using a Core Facility
based at Arkansas Children's Hospital (ACH). The CTN recently expanded
its existing Core C, a Community Based Research and Education Core
Facility established in August, 2006, and which has been gathering
preliminary data on low birth weights around the State. An
Administrative Supplement from NCRR allowed the purchase of equipment
for real-time teleconferencing and transmission of high-quality images.
Low birth weight (LBW) births are a leading cause
of death and disability in infants, major sources of stress for parents,
and an economic burden for private and public health insurance
programs. Delivery at hospitals offering specialized pre- and perinatal
care is thought to be effective in improving birth outcomes and perhaps
reducing medical costs. However, women residing in rural and
underserved areas typically lack access to these centers and to maternal
and fetal medicine subspecialists who can assist community physicians
with diagnosis and management of high-risk conditions.
Last year, the CTN began support for a Core
Facility in conjunction with a statewide network of 15 clinics and began
gathering preliminary data as described below. We expanded this Core to
include interactive compressed video, a centralized call center, and a
statewide physician education and guideline development initiative to
enable women and their community physicians to consult with academic
subspecialists and facilitate the evidence-based referral of high-risk
women to regional perinatal centers for delivery. In addition to these
educational activities, the COBRE Core Facility will gather research
data on birth outcomes.
We will attempt to determine, a) if this program
will shift patterns of delivery for high-risk pregnancies in Arkansas,
with a specific focus on women residing in rural and underserved areas
of the state. If the program is effective in improving evidence-based
referral of high-risk pregnancies to regional perinatal centers, we
would expect to see increases in the volume of premature/LBW births
delivered at the state's academic medical center, which offers the most
advanced maternal-fetal services in the state, and possibly also
increases in volume at other Level III hospitals within the state.
Correspondingly, this program is expected to reduce the volume of
premature/LBW infants delivered at non-Level III hospitals, including
those infants that require transfer to a children's hospital or other
specialized perinatal facility after delivery; b) outcomes from a single
rural state (Arkansas) with one medical center (UAMS) serving an
entirely inborn population and a large children's hospital (ACH) serving
an entirely outborn population. UAMS and ACH are both run by a single
academic neonatology group who oversees the daily care and provides
round the clock in-house neonatology coverage, facilitating data
gathering and assessment; and c) the costs of LBW to medical centers and
to parents, and data on the satisfaction of parents in the process.
For example, we will gather preliminary data on
such factors as outcomes of LBW by birth weight, by county, and by care
level ("rural" no neonatologist; "level III" neonatologist not
associated with an academic center; and "UAMS" an academic center with
subspecialty coverage). We will also assess the shift in patterns of
referrals resulting from weekly telemedicine conferences, 24 hr call
center, and patterns of consultation. Although ultrasounds can be read
real-time with current technology, we implemented the capacity for
remote assessment of X-rays to complement consultation services. We
already have gathered some preliminary data.
We will address two main issues
related to prematurity and low birth weight: 1) Are neonatal outcomes
improved by regionalization of perinatal care? and 2) Are long-term
outcomes improved by subspecialty care and follow-up? We will,
therefore, assess 1) mortality, morbidity and costs of academic vs
community hospital medical care, and 2) if these are improved through
dissemination of evidence based guidelines and research to community
physicians using weekly neonatology telemedicine conferences.
In the U.S., 60,000 babies per year
are born <1500 gm, and 20,000 babies per year are born <1000 gm. The
rate of preterm delivery is increasing with the causes being
multifactorial and societal, however, there have been few changes in
preterm delivery rates or survival rates. In Arkansas, 43% of births
are in rural settings with UAMS providing the sole perinatal delivery
service. 73/75 counties are designated as underserved. While
regionalization and maternal transport improve outcomes in the smallest
babies, intensive newborn care provides money and prestige to hospitals,
leading to deregionalization, with inappropriate referrals leading to
overcrowding at referral centers. We instituted a system of matching
birth records, death certificates and hospital records with 91% match,
allowing us to assess mortality, morbidity and costs. Our results show:
Figure 1 above shows the risk of death
within 60 days of birth by weight and delivery hospital. Note that the
mortality of the lowest birth weights (500-999 gm) is much higher at
hospitals without a neonatal intensive care unit (NICU) compared to UAMS
(P<0.01). The mortality rate is still higher (P<0.05) at 1000-1499 gm
in hospitals without NICU compared to UAMS. On the other hand,
mortality for higher weight infants, 1500-2499 gm, is not significantly
better. These data suggest that only certain infants may need to be
transferred to UAMS or a hospital with a NICU.
Figure 2 above shows that neurodevelopmental
outcomes from grades 3 and 4 intraventricular hemorrhage (IVH) for
inborn delivery are considerably better, regardless of weight, when the
delivery takes place at the UAMS NICU (inborns) compared to Arkansas
Childrens Hospital (ACH) (outborns).
Figure 3 above shows that the costs of
perinatal care over the first four years of life for a single case with
a birth weight or 500-750 gm are >$600,000 if there is intraventricular
hemorrhage (IVH) but <$200,000 if there is none. The costs of IVH
decline dramatically with higher birth weights.
Figure 4 Above shows the average costs of
newborn care for low birth weight babies. Please note that the average
cost per year per patient over 2500 gm is $3723. However, the costs per
patient, including Medicaid charges over 12 months such as inpatient
hospital, outpatient hospital, professional services, drugs and other
costs are almost $160,000 in hospitals without a NICU compared to
~$100,000 for UAMS for babies <100 gm, but costs are very similar for
babies 1000-1500 gm.
These are the kinds of data that we
can generate in the Core Facility. We hope to provide much more
detailed information on the need and potential impact of this program
using the expansion into real-time teleconferencing and high quality
video imaging. In addition to information about populations, outcomes
and costs, we believe the educational value of this telemedicine effort
will be reflected in an actual decrease in mortality, reason enough for
its support. The Core Facility will be directed by R. Whit Hall, MD, a
neonatologist based at ACH and UAMS, and a CTN investigator. Dr. Hall
will work closely with ongoing outreach efforts by the Department of
Obstetrics and Gynecology (ANGELS), with the Arkansas Medicaid Program
and with the Agency for Health Research and Quality (AHRQ) for Medicaid.