Use of evidence based practices to improve survival without severe morbidity for very preterm infants: Results from the EPICE population based cohort

Jennifer Zeitlin, Bradley N. Manktelow, Aurelie Piedvache, Marina Cuttini, Elaine Boyle, Arno Van Heijst, Janusz Gadzinowski, Patrick Van Reempts, Lene Huusom, Tom Weber, Stephan Schmidt, Henrique Barros, Dominico Dillalo, Liis Toome, Mikael Norman, Beatrice Blondel, Mercedes Bonet, Elisabeth S. Draper, Rolf F. Maier

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Abstract

To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity. Design Prospective multinational population based observational study. Setting 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project. Participants 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission. Main outcom e measures Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥ 36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital. Results Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants. Conclusions More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.

Original languageEnglish
Article numberi2976
JournalBritish Medical Journal
Volume354
DOIs
Publication statusPublished - 2016

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Evidence-Based Practice
Premature Infants
Morbidity
Hospital Mortality
Population
Odds Ratio
Parturition
Perinatal Care
Pregnancy
Propensity Score
Continuous Positive Airway Pressure
Apgar Score
Premature Birth
Infant Mortality
Critical Care
Hypothermia
Surface-Active Agents
Gestational Age
Observational Studies
Cluster Analysis

ASJC Scopus subject areas

  • Medicine(all)

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Use of evidence based practices to improve survival without severe morbidity for very preterm infants : Results from the EPICE population based cohort. / Zeitlin, Jennifer; Manktelow, Bradley N.; Piedvache, Aurelie; Cuttini, Marina; Boyle, Elaine; Van Heijst, Arno; Gadzinowski, Janusz; Van Reempts, Patrick; Huusom, Lene; Weber, Tom; Schmidt, Stephan; Barros, Henrique; Dillalo, Dominico; Toome, Liis; Norman, Mikael; Blondel, Beatrice; Bonet, Mercedes; Draper, Elisabeth S.; Maier, Rolf F.

In: British Medical Journal, Vol. 354, i2976, 2016.

Research output: Contribution to journalArticle

Zeitlin, J, Manktelow, BN, Piedvache, A, Cuttini, M, Boyle, E, Van Heijst, A, Gadzinowski, J, Van Reempts, P, Huusom, L, Weber, T, Schmidt, S, Barros, H, Dillalo, D, Toome, L, Norman, M, Blondel, B, Bonet, M, Draper, ES & Maier, RF 2016, 'Use of evidence based practices to improve survival without severe morbidity for very preterm infants: Results from the EPICE population based cohort', British Medical Journal, vol. 354, i2976. https://doi.org/10.1136/bmj.i2976
Zeitlin, Jennifer ; Manktelow, Bradley N. ; Piedvache, Aurelie ; Cuttini, Marina ; Boyle, Elaine ; Van Heijst, Arno ; Gadzinowski, Janusz ; Van Reempts, Patrick ; Huusom, Lene ; Weber, Tom ; Schmidt, Stephan ; Barros, Henrique ; Dillalo, Dominico ; Toome, Liis ; Norman, Mikael ; Blondel, Beatrice ; Bonet, Mercedes ; Draper, Elisabeth S. ; Maier, Rolf F. / Use of evidence based practices to improve survival without severe morbidity for very preterm infants : Results from the EPICE population based cohort. In: British Medical Journal. 2016 ; Vol. 354.
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abstract = "To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity. Design Prospective multinational population based observational study. Setting 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project. Participants 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission. Main outcom e measures Combined use of four evidence based practices for infants born before 28 weeks' gestation using an {"}all or none{"} approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥ 36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital. Results Only 58.3{\%} (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95{\%} confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18{\%} decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants. Conclusions More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.",
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AU - Zeitlin, Jennifer

AU - Manktelow, Bradley N.

AU - Piedvache, Aurelie

AU - Cuttini, Marina

AU - Boyle, Elaine

AU - Van Heijst, Arno

AU - Gadzinowski, Janusz

AU - Van Reempts, Patrick

AU - Huusom, Lene

AU - Weber, Tom

AU - Schmidt, Stephan

AU - Barros, Henrique

AU - Dillalo, Dominico

AU - Toome, Liis

AU - Norman, Mikael

AU - Blondel, Beatrice

AU - Bonet, Mercedes

AU - Draper, Elisabeth S.

AU - Maier, Rolf F.

PY - 2016

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N2 - To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity. Design Prospective multinational population based observational study. Setting 19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project. Participants 7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission. Main outcom e measures Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥ 36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital. Results Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants. Conclusions More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.

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