Background: Neonatal care for preterm babies is prolonged and expensive. Our aim was to analyze and report costs associated with common preterm diagnoses during NICU stay.Methods: We analyzed data from the Ontario healthcare data service. Diagnoses were collated by discharge ICD codes, and categorized by gestational age. We calculated typical non parametric statistics, and for each diagnosis we calculated median shifts and generalized linear mode.Results: We included data on 12,660 infants between 23 and 30 weeks gestation in 2005-2017. Calculated cost increment with diagnosis were: Intestinal obstruction: $94,738.08 (95%CI: $70,093.3, $117,294.2), Ventriculoperitoneal shunt: $86,456.60 (95%CI: $60,773.7, $111,552.2), Chronic Lung Disease $77,497.70 (95%CI: $74,937.2, $80,012.8), Intestinal perforation $57,997.15 (95%CI:$45,324.7, $70,652.6), Retinopathy of Prematurity: $55,761.80 (95%CI: $53,916.2, $57,620.1), Patent Ductus Arteriosus $53,453.70 (95%CI: $51,206.9, $55692.7, Post-haemorrhagic ventriculomegaly $41,822.50 (95%CI: $34,590.4, $48,872.4), Necrotizing Enterocolitis $39,785 (95%CI: $35,728.9, $43,879), Meningitis $38,871.85 (95%CI: $25,272.7, $52,224.4), Late onset sepsis $32,954.20 (95%CI: $30,403.7, 35.515), Feeding difficulties $24,820.90 (95%CI: $22,553.3, $27,064.7), Pneumonia $23,781.70 (95%CI: $18,623.8, $28,881.6), Grade >2 Intraventricular Haemorrhage $14,777.38 (95%CI: $9,821.7, $20,085.2). Adjusted generalized linear model of diagnoses as coefficients for cost confirmed significance and robustness of the model.Conclusion: Cost of care for preterm infant is expensive, and significantly increases with prematurity complication. Interventions to reduce those complications may enable resource allocation and better understanding of the needs of the neonatal health services.

Purpose: A mapping review to quantify representation of vulnerable populations, who suffer from disparity and often inequitable healthcare, in quality improvement (QI) research. Data sources: Studies published in 2004-2014 inclusive from Medline, Embase and Cochrane data-bases for English language research with the terms 'quality improvement' or 'quality control' or 'QI' and 'plan-do-study-act' or 'PDSA' in the years 2004-2014 inclusively. Study selection: Published clinical research that was a QI-themed, as identified by its declared search terms, MESH terms, abstract or title. Data extraction: Three reviewers identified the eligible studies independently. Excluded were publications that were not trials, evaluations or analyses. Results of data synthesis: Of 2039 results, 1660 were eligible for inclusion. There were 586 (33.5%) publications that targeted a specific vulnerable population: children (184, 10.54%), mental health patients (125, 7.16%), the elderly (100, 5.73%), women (57, 3.27%), the poor (30, 1.72%), rural residents (29, 1.66%), visible minorities (27, 1.55%), the terminally ill (17, 0.97%), adolescents (16, 0.92%) and prisoners (1 study). Seventy-four articles targeted two or more vulnerable populations, and 11 targeted three population categories. On average, there were 158 QI research studies published per year, increasing from 69 in 2004 to 396 in 2014 (R-2 = 0.7, P < 0.001). The relative representation of vulnerable populations had a mean of 33.58% and was stable over the time period (standard deviation (SD) = 5.9%, R-2 = 0.001). Seven countries contributed to over 85% of the publications targeting vulnerable populations, with the USA contributing 62% of the studies. Conclusions: Over 11 years, there has been a marked increase in QI publications. Roughly one-third of all published QI research is on vulnerable populations, a stable proportion over time. Nevertheless, some vulnerable populations are under-represented. Increased education, resources and attention are encouraged to improve the health of vulnerable populations through focused QI initiatives.

Background: Neonatal intensive care is expensive and prolonged. Extremely preterm infants are routinely supported. The costs for this practice at the age of borderline viability are of interest to clinicians and policymakers. Methods: We analyzed data from the Canadian national administrative database on total cost and length of hospital care from a public payor perspective for 23–28-week premature infants from 2011 to 2015. We also compared total and daily costs for 23–25-week newborns. Each comparison evaluated the total cohort and infants who lived more than 3 days. We used non-parametric tests, correlation tests, and generalized linear models for cost difference analysis, adjusting for survival, length of stay, and year. Results: We analyzed 6,932 infants’ cost records. For all infants, median length of hospital stay was 41 days (IQR, 1–77 days). For infants who survived the first 3 days, median length of stay was 61 days (IQR, 34–90 days). The median total cost was $66,669 (IQR, $4,920–$125,550). For infants who survived the first 3 days, median total cost was $91,137 (IQR, $56,596–$188,757). For infants who survived the first 3 days, median total costs were $147,835 (IQR, $44,711–$233,847) for 23-week infants, $154,736 (IQR, $61,160–$248,290) for 24-week infants, and $130,317 (IQR, $79,737–$229,058) for 25-week infants. These amounts did not differ (P>0.7). Conclusions: Total and daily costs of neonatal intensive care are high. Total cost was not different between surviving 23–25-week infants. These findings highlight the need for a funding strategy for the routine support of these fragile infants.

OBJECTIVES: Inhaled nitric oxide (iNO) remains the “gold standard” therapy for hypoxemic respiratory failure in newborns. Despite good quality evidence to guide iNO use in this population, we observed considerable practice variation, particularly in timing and rate of weaning. To promote evidence-based practice, we launched an iNO stewardship program in April 2013. Our objective was to determine whether iNO stewardship led to changes in iNO utilization and weaning.METHODS: We conducted a quality improvement project in an outborn quaternary NICU, targeting improved iNO guideline compliance. We compared patterns of iNO utilization between 2 cohorts: prestewardship (April 2011–March 2013; retrospective data collection) and poststewardship (April 2013–March 2015; prospective data collection).RESULTS: Eighty-seven neonates received 88 courses of iNO in the 2 years prestewardship, and 64 neonates received 64 courses of iNO in the 2 years poststewardship. There were no significant differences (P > .05) in patient demographics, in the proportion of patients receiving iNO “off-label,” in proportion initiated at the referring hospital, or in outcomes (death or extracorporeal membrane oxygenation). There were significant (P < .05) reductions in median total hours on iNO per patient (47 vs 20; P < .001), in iNO hours per patient from maximum dose to initial wean (28 vs 9; P < .01), and in hours from initial wean to discontinuation (14 vs 8; P < .05).CONCLUSIONS: The introduction of iNO stewardship was associated with improved adherence to evidence-based guidelines and an overall reduction in total and per-patient iNO use.

Background: Necrotizing Enterocolitis (NEC) is a severe intestinal inflammatory disease due to multifactorial causes that present in preterm infants. Compared with similar neonatal intensive care units, our NEC rate was increasing and prompted reduction by a quality improvement (QI) intervention. Methods: We aimed to reduce NEC rate by 30% by the end of 2016. We used the Institute of Healthcare Improvement model and typical QI tools, including teamwork, process organizing tools, and evidence-based review, to assist in our selection of supplementation of Lactobacillus reuteri probiotic. We used education, process mapping, process control statistics, and forcing mechanism to implement the changes. In addition to reducing NEC rates, our additional outcome measures were sepsis, mortality, sepsis evaluations, feeding intolerance, growth, days of both antimicrobials, and parenteral nutrition use. Process measures were compliance with probiotics supplementation policy and balancing measures were sepsis rates and feeding intolerance. Results: NEC rates decreased from 4.4% to the current 1.7%, and in a pre/post-intervention analysis, the results were significant in all patient subcategories. We did not demonstrate a reduction in mortality. No adverse events occurred. Feeding intolerance episodes and days nil-per-os decreased with no differences in growth at discharge. These results continued over 2 years, and this practice has already spread to several neonatal intensive care units in Ontario, Canada. Conclusions: We utilized QI methods and tools to implement a successful practice change of routine probiotic supplementation to reduce NEC rates in preterm infants. We suggest considering this intervention as a successful means to prevent this serious illness.