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Telemedicine Core

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.
AR SAVES Map as EdsPLACE AR SAVES.pdf
 

Community Based Research and Education  (COBRE) Core Facility

 Please view our latest poster from our Community Based Research and Education (CoBRE) Core Facility

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. 

Specific Aims

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.