neonatal mortality of vlbw in europe the portuguese experience portuguese vlbw infants network...
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Neonatal Mortality of VLBW in EuropeThe Portuguese Experience
Portuguese VLBW Infants Network
Hercília Guimarã[email protected]
Brussels, December 2009
10 millions inhabitants
100000 births / year
Universal National Healthcare
Perinatal Care System
VLBWRegister
Perinatal
Early neonatal
Late Fetal
Perinatal, late fetal and early neonatal mortality rate, Portugal 1980-2005
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
InfantMortality(‰)
7.4 6.9 6.4 6.0 5.6 5.5 5.0 5.0 4.1 3.8 3.5 3.3 3.4 3.3
PerinatalMortality(‰)
9.0 8.4 7.2 6.8 6.4 6.2 5.6 6.0 5.1 4.4 4.3 4.6 4.3 4.0
Neonatal mortality(‰)
4.7 4.2 4.1 3.7 3.6 3.4 2.9 3.4 2.7 2.6 2.2 2.8 2.0 2.1
Foetal morality(‰)
5.5 5.4 4.4 4.0 3.7 3.7 3.4 3.4 3.1 2.7 2.8 3.1 3.6 3.2
Perinatal, neonatal and infant mortality evolution
Portuguese Perinatal Healthcare Policy National Committee for mother and child healthcare (1989)
Maternities with < 1500 deliveries/year were closed
Hospitals were classified as Level II and Level III
Functional Coordinating Units connect the Hospitals to the Primary Healthcare Centers
The post graduation of Paediatricians in Neonatology originated the creation of the Special Studies on Neonatology Cycle.
Transport in utero was recognized as the best
Neonatal transport – INEM, was created as an alternative.
Local Health Center
Local Health Center
Local Health Center
Local Health Center
Level II HospitalIntermediate
Neonatal Care
Level II HospitalIntermediate
Neonatal Care
Level III Hospital
Neonatal Intensive
Care Unit
Intensive care beds by center 5-13
>50 VLBW infants 10/21
Surgical centers Surgeries/year:2>70;1>40
Cardiac centers 2 south;1 center;1 north
Public hospitals with perinatal care
Level II-27 Level III-21 (including islands)
North
Center
South
National Neonatal Transport
3 centers placed in level 3 hospitals
Centralized information system
Ambulance equipped with a NICU, and nurse and doctor with expertise in neonatal transport
Neonatal MortalityPortugal 2007/ VLBW Network
0
50
100
150
200
250
23-27 28-31 32-36 Total
VLBW Death Neonatal death
< 32weeks49% of neonatal mortality
VLBW Network 1994-2009Neonatal Society
Portuguese VLBW Infants Network - 1994
To consolidate a Network of multicenter prospective neonatal studies
To integrate clinical research in activities of assistence
To determine the prevalence of VLBW in Portugal and the contribution in the mortality and morbidity
To analyse the efficiency of neonatal regionalization
To monitor clinical practices in order to have a national standard for the self-assessement
Main Goals
Methods
VLBW infants 500-1499gr (1994-98); 401-1499gr (>1998)
Central Coordination – Coimbra Data Base on line: htpp//downloads.lusoneonatologia.net
National Meetings (objectives and methods)
Integration in clinical practice – Registration Form Collective and voluntary participation
Portuguese VLBW Network
0
10
20
30
40
50Level III Level II
Level II 0 14 16 15 14 13 13 13 14 17
Level III 13 18 18 20 22 23 23 23 23 23
1994 1996 1997 1998 1999 2000 2001 2002 2003 >2004
VLBW infants - Portuguese NetworkParticipating NICU´s
VLBW National NetworkCover rate
1994 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
VLBW 660 830 828 897 979 1041 977 1029 1001 1016 1006 880 860 832
NIS 830 892 913 974 1183 1138 990 1067 964 1021 1012 916 934 900
0
200
400
600
800
1000
1200
1400
Reg
iste
rs
100%
0
200
400
600
800
1000
1200
0
0,2
0,4
0,6
0,8
1
1,2
VLBW (n) 660 830 897 1041 977 1029 1001 1016 1030 911 1024
Prevelence 0,66 0,81 0,86 0,94 0,88 0,92 0,88 0,92 0,94 0,83 0,99
1994 1996 1998 2000 2001 2002 2003 2004 2005 2006 2007
n %
Portuguese VLBW database 1994 - 2004
The Portuguese VLBW Network VLBW Prevalence (%)
European Perinatal Health Report,2008
Portuguese VLBW Infants NetworkRegionalization
0 25 50 75 100
In uterus transport
Level 3
Neonatal transport
Return transport
30
90
5,6
30
17
2005-2008
Nº = 3561
REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009
Secção de Neonatologia - SPP
Place of delivery – 10 years evolution
1996 2005
In uterus transport
176 (21%) 374 (37%) P<0.001
Birth in level III 678 (82%) 920 (92%) P<0.001
Neonatal transport
124 (15%) 79 (8%) P<0.001
In born 706( 85%) 921 (92%) P<0.001
Portuguese VLBW Network
706 719 776 886 950 910 923922 884
0%10%20%30%40%50%60%70%80%90%
100%
1996 1997 1998 1999 2000 2001 2002 2003 2004
OUT
IN
15%
9%
Effectiveness of regionalization.
It worthes to avoid neonatal transport.
Europeristat 2008
The Portuguese VLBW Network
VLBW 2000-2004
n=5034VLBW 2004
n=1016
n Deaths %
IN 4523 780 17.2
OUT 514 136 26.5
P<0.001
n Deaths %
IN 923 133 14.4
OUT 93 25 26.9
P<0.001
It worthes to be born in the right place.
Portuguese VLBW Network Evolution of mortality per BW
0
10
20
30
40
50
60
Mortality <1000g 54 47 43 39 40 34 41 38 29 27 26
Mortality > 1000g 12 12 10 10 8 7,3 8 7 7 4 4,4
1996 1997 1998 1999 2000 2001 2002 2003 2004 2006 2007
Improving the efficiency in ELBW
Portuguese VLBW Infants NetworkPerinatal data
0 25 50 75 100
Prenatal care
Prenatal steroids
CST
ETT in delivery room
92,4
86
72
56,3
23
Nº = 3561
REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009
Secção de Neonatologia - SPP
85 %
85 %
6.521%
8,58%
4.9%
EuroNeoNet 2007
Threshold of Viability Birth Weight
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Live birth
Dead
25
2005-2008
Nº = 3561
REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009
Secção de Neonatologia - SPP
2005-2008n = 3561
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Live Birth
Dead
26
2005-2008 Nº = 3561
REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009
Secção de Neonatologia - SPP
Threshold of Viability (GA)
2005-2008n = 3561
Portuguese VLBW Network
Threshold of viability >50% alive 1996 – 27 w1997 – 26 w
>2004 – 25 w
Threshold of survival without major sequelae
1996 – 29 w1997 – 28 w
>2004 – 27 w
22 w GA: no survivors23 w GA: rare24 w: survival rate - 38 %
Portuguese VLBW NetworkMorbidity
Morbidity (%) 1996 2000 2006 2007
RDS 57 60 73 73
PDA 23 19 20 19
BPD (O2 36 w) 23 22 8.8 8.3
ROP 21 19 19.3 15
IVH (III,IV) 6.2 6.2 7.4 7.1
PVL 6.6 4.4 6 3.4
NEC (II,III) 5.3 4.3 6.3 3.6
Nos.Sepsis 32 31 26.5 29.6
EuroNeoNet 2007
53,8%9%
65%42%19%
2.41.71.12.736%
92%8,7%
4,2%
4,1%20,8%
5,6 %
61,5%24,7%3,7%
Portuguese VLBW Network
The aims of regionalisation were achieved.
The perinatal care reform in Portugal is an example of how a good diagnosis and adequate proposals combined with a strong political will is important for changing .
Conclusions
Portuguese VLBW Infants Network
To keep the benefits of organizational measures
To improve Follow-up of VLBW infants at 36 m and 5 years
To promote self-evaluation of NICU´s (Quality)
To improve Network of Neonatal Research
The next years objectives