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Jeffrey D. Horbar
Department of Pediatrics, Robert Larner, MD College of Medicine, University of Vermont, Burlington, VT 05405, USA

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Journal article
Published: 07 May 2019 in Children
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The Textbook of Neonatal Resuscitation, seventh edition, does not suggest routine endotracheal suctioning for non-vigorous infants born through meconium-stained amniotic fluid. We compared 301,150 infants at ≥35 weeks’ gestational age inborn at 311 Vermont Oxford Network member centers in the United States (U.S.) and admitted to neonatal intensive care units (NICU) who were born before (2013 to 2015) and after (2017) the guideline change. Logistic regression models adjusting for clustering of infants within centers were used to calculate risk ratios. NICU admissions for infants with a diagnosis of meconium aspiration syndrome (MAS) decreased from 1.8% to 1.5% (risk ratio: 0.82; 95% confidence interval: 0.68, 0.97) and delivery room endotracheal suctioning in this group decreased from 57.0% to 28.9% (0.51; 0.41, 0.62). Treatment with conventional or high frequency ventilation, inhaled nitric oxide, or extracorporeal membrane oxygenation remained unchanged 42.3% vs. 40.3% (0.95; 0.80, 1.13) among infants with MAS and 9.1% vs. 8.2% (0.91; 0.87, 0.95) among infants without MAS. The use of surfactant among infants with MAS increased from 24.6% to 30% (1.22; 1.02, 1.48). Mortality (2.6 to 2.9%, 1.12; 0.74, 1.69) and moderate/severe hypoxic-ischemic encephalopathy (5.4 to 6.8%, 1.24; 0.91, 1.69) increased slightly in 2017. Subgroup analyses of infants with 1 min Apgar scores of ≤3 found similar results. While NICU admissions for MAS and tracheal suctioning decreased after the introduction of the new guideline with no subsequent increase in severe respiratory distress among infants with and without a MAS diagnosis, limitations in our study preclude inferring that the new guideline is safe or effective.

ACS Style

Erika Edwards; SatyaN Lakshminrusimha; Danielle Ehret; Jeffrey Horbar. NICU Admissions for Meconium Aspiration Syndrome before and after a National Resuscitation Program Suctioning Guideline Change. Children 2019, 6, 68 .

AMA Style

Erika Edwards, SatyaN Lakshminrusimha, Danielle Ehret, Jeffrey Horbar. NICU Admissions for Meconium Aspiration Syndrome before and after a National Resuscitation Program Suctioning Guideline Change. Children. 2019; 6 (5):68.

Chicago/Turabian Style

Erika Edwards; SatyaN Lakshminrusimha; Danielle Ehret; Jeffrey Horbar. 2019. "NICU Admissions for Meconium Aspiration Syndrome before and after a National Resuscitation Program Suctioning Guideline Change." Children 6, no. 5: 68.

Journal article
Published: 20 November 2018 in PEDIATRICS
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Video Abstract BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Core Elements of Hospital Antibiotic Stewardship Programs (ASPs), while the Choosing Wisely for Newborn Medicine Top 5 list identified antibiotic therapy as an area of overuse. We identify the baseline prevalence and makeup of newborn-specific ASPs and assess the variability of NICU antibiotic use rates (AURs). METHODS: Data were collected using a cross-sectional audit of Vermont Oxford Network members in February 2016. Unit measures were derived from the 7 domains of the CDC’s Core Elements of Hospital ASPs, including leadership commitment, accountability, drug expertise, action, tracking, reporting, and education. Patient-level measures included patient demographics, indications, and reasons for therapy. An AUR, defined as the number of infants who are on antibiotic therapy divided by the census that day, was calculated for each unit. RESULTS: Overall, 143 centers completed structured self-assessments. No center addressed all 7 core elements. Of the 7, only accountability (55%) and drug expertise (62%) had compliance >50%. Centers audited 4127 infants for current antibiotic exposure. There were 725 infants who received antibiotics, for a hospital median AUR of 17% (interquartile range 10%–26%). Of the 412 patients on >48 hours of antibiotics, only 26% (107 out of 412) had positive culture results. CONCLUSIONS: Significant gaps exist between CDC recommendations to improve antibiotic use and antibiotic practices during the newborn period. There is wide variation in point prevalence AURs. Three-quarters of infants who received antibiotics for >48 hours did not have infections proven by using cultures.

ACS Style

Timmy Ho; Madge E. Buus-Frank; Erika M. Edwards; Kate A. Morrow; Karla Ferrelli; Arjun Srinivasan; Daniel A. Pollock; Dmitry Dukhovny; John A.F. Zupancic; DeWayne M. Pursley; Roger F. Soll; Jeffrey D. Horbar. Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations. PEDIATRICS 2018, 142, e20174322 .

AMA Style

Timmy Ho, Madge E. Buus-Frank, Erika M. Edwards, Kate A. Morrow, Karla Ferrelli, Arjun Srinivasan, Daniel A. Pollock, Dmitry Dukhovny, John A.F. Zupancic, DeWayne M. Pursley, Roger F. Soll, Jeffrey D. Horbar. Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations. PEDIATRICS. 2018; 142 (6):e20174322.

Chicago/Turabian Style

Timmy Ho; Madge E. Buus-Frank; Erika M. Edwards; Kate A. Morrow; Karla Ferrelli; Arjun Srinivasan; Daniel A. Pollock; Dmitry Dukhovny; John A.F. Zupancic; DeWayne M. Pursley; Roger F. Soll; Jeffrey D. Horbar. 2018. "Adherence of Newborn-Specific Antibiotic Stewardship Programs to CDC Recommendations." PEDIATRICS 142, no. 6: e20174322.

Review
Published: 02 May 2018 in Conflict and Health
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In the ongoing conflicts of Syria and Yemen, there have been widespread reports of attacks on health care facilities and personnel. Tabulated evidence does suggest hospital bombings in Syria and Yemen are far higher than reported in other conflicts but it is unclear if this is a reporting artefact. This article examines attacks on health care facilities in conflicts in six middle- to high- income countries that have occurred over the past three decades to try and determine if attacks have become more common, and to assess the different methods used to collect data on attacks. The six conflicts reviewed are Yemen (2015-Present), Syria (2011- Present), Iraq (2003-2011), Chechnya (1999-2000), Kosovo (1998-1999), and Bosnia and Herzegovina (1992-1995). We attempted to get the highest quality source(s) with summary data of the number of facilities attacked for each of the conflicts. The only conflict that did not have summary data was the conflict in Iraq. In this case, we tallied individual reported events of attacks on health care. Physicians for Human Rights (PHR) reported attacks on 315 facilities (4.38 per month) in Syria over a 7-year period, while the Monitoring Violence against Health Care (MVH) tool launched later by the World Health Organization (WHO) Turkey Health Cluster reported attacks on 135 facilities (9.64 per month) over a 14-month period. Yemen had a reported 93 attacks (4.65 per month), Iraq 12 (0.12 per month), Chechnya > 24 (2.4 per month), Kosovo > 100 (6.67 per month), and Bosnia 21 (0.41 per month). Methodologies to collect data, and definitions of both facilities and attacks varied widely across sources. The number of reported facilities attacked is by far the greatest in Syria, suggesting that this phenomenon has increased compared to earlier conflicts. However, data on attacks of facilities was incomplete for all of the conflicts examined, methodologies varied widely, and in some cases, attacks were not defined at all. A global, standardized system that allows multiple reporting routes with different levels of confirmation, as seen in Syria, would likely allow for a more reliable and reproducible documentation system, and potentially, an increase in accountability.

ACS Style

Carolyn Briody; Leonard Rubenstein; Les Roberts; Eamon Penney; William Keenan; Jeffrey Horbar. Review of attacks on health care facilities in six conflicts of the past three decades. Conflict and Health 2018, 12, 19 .

AMA Style

Carolyn Briody, Leonard Rubenstein, Les Roberts, Eamon Penney, William Keenan, Jeffrey Horbar. Review of attacks on health care facilities in six conflicts of the past three decades. Conflict and Health. 2018; 12 (1):19.

Chicago/Turabian Style

Carolyn Briody; Leonard Rubenstein; Les Roberts; Eamon Penney; William Keenan; Jeffrey Horbar. 2018. "Review of attacks on health care facilities in six conflicts of the past three decades." Conflict and Health 12, no. 1: 19.

Multicenter study
Published: 01 September 2017 in The Journal of Pediatrics
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To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.

ACS Style

Brenna S. Fullerton; Cristine S. Velazco; Eric A. Sparks; Kate A. Morrow; Erika M. Edwards; Roger F. Soll; Biren P. Modi; Jeffrey D. Horbar; Tom Jaksic. Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study. The Journal of Pediatrics 2017, 188, 192 -197.e6.

AMA Style

Brenna S. Fullerton, Cristine S. Velazco, Eric A. Sparks, Kate A. Morrow, Erika M. Edwards, Roger F. Soll, Biren P. Modi, Jeffrey D. Horbar, Tom Jaksic. Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study. The Journal of Pediatrics. 2017; 188 ():192-197.e6.

Chicago/Turabian Style

Brenna S. Fullerton; Cristine S. Velazco; Eric A. Sparks; Kate A. Morrow; Erika M. Edwards; Roger F. Soll; Biren P. Modi; Jeffrey D. Horbar; Tom Jaksic. 2017. "Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study." The Journal of Pediatrics 188, no. : 192-197.e6.

Observational study
Published: 01 March 2017 in JAMA Pediatrics
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Hospitals use rates from the best quartile or decile as benchmarks for quality improvement aims, but to what extent these aims are achievable is uncertain. To determine the proportion of neonatal intensive care units (NICUs) in 2014 that achieved rates for death and major morbidities as low as the shrunken adjusted rates from the best quartile and decile in 2005 and the time it took to achieve those rates. A total of 408 164 infants with a birth weight of 501 to 1500 g born from January 1, 2005, to December 31, 2014, and cared for at 756 Vermont Oxford Network member NICUs in the United States were evaluated. Logistic regression models with empirical Bayes factors were used to estimate standardized morbidity ratios for each NICU. Each ratio was multiplied by the overall network rate to calculate the 10th, 25th, 50th, 75th, and 90th percentiles of the shrunken adjusted rates for each year. The proportion in 2014 that achieved the 10th and 25th percentile rates from 2005 and the number of years it took for 75% of NICUs to achieve the 2005 rates from the best quartile were estimated. Death prior to hospital discharge, infection more than 3 days after birth, severe retinopathy of prematurity, severe intraventricular hemorrhage, necrotizing enterocolitis, and chronic lung disease among infants less than 33 weeks' gestational age at birth. Of the 756 hospitals, 695 provided data for 2014. The mean unadjusted infant-level rate of death before hospital discharge decreased from 14.0% in 2005 to 10.9% in 2014. In 2014, 689 of 695 NICUs (99.1%; 95% CI, 97.4%-100.0%) achieved the 2005 shrunken adjusted rates from the best quartile for death prior to discharge, 678 of 695 (97.6%; 95% CI, 95.8%-99.6%) for late-onset infection, 558 of 681 (81.9%; 95% CI, 77.2%-86.6%) for severe retinopathy of prematurity, 611 of 693 (88.2%; 95% CI, 81.7%-97.0%) for severe intraventricular hemorrhage, 529 of 696 (76.0%; 95% CI, 71.8%-81.2%) for necrotizing enterocolitis, and 286 of 693 (41.3%; 95% CI, 36.1%-45.6%) for chronic lung disease. It took 3 years before 445 NICUs (75.0%) achieved the 2005 shrunken adjusted rate from the best quartile for death prior to discharge, 5 years to achieve the rate from the best quartile for late-onset infection, 6 years to achieve the rate from the best quartile for severe retinopathy of prematurity and severe intraventricular hemorrhage, and 8 years to achieve the rate from the best quartile for necrotizing enterocolitis. From 2005 to 2014, rates of death prior to discharge and serious morbidities decreased among the NICUs in this study. Within 8 years, 75% of NICUs achieved rates of performance from the best quartile of the 2005 benchmark for all outcomes except chronic lung disease. These findings provide a novel way to quantify the magnitude and pace of improvement in neonatology.

ACS Style

Jeffrey D. Horbar; Erika M. Edwards; Lucy T. Greenberg; Kate A. Morrow; Roger F. Soll; Madge E. Buus-Frank; Jeffrey S. Buzas. Variation in Performance of Neonatal Intensive Care Units in the United States. JAMA Pediatrics 2017, 171, e164396 .

AMA Style

Jeffrey D. Horbar, Erika M. Edwards, Lucy T. Greenberg, Kate A. Morrow, Roger F. Soll, Madge E. Buus-Frank, Jeffrey S. Buzas. Variation in Performance of Neonatal Intensive Care Units in the United States. JAMA Pediatrics. 2017; 171 (3):e164396.

Chicago/Turabian Style

Jeffrey D. Horbar; Erika M. Edwards; Lucy T. Greenberg; Kate A. Morrow; Roger F. Soll; Madge E. Buus-Frank; Jeffrey S. Buzas. 2017. "Variation in Performance of Neonatal Intensive Care Units in the United States." JAMA Pediatrics 171, no. 3: e164396.

Journal article
Published: 01 June 2016 in Journal of Pediatric Surgery
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The objectives of this study were to evaluate mortality rates in very low birth weight (VLBW) infants with surgical necrotizing enterocolitis (NEC) by level of available surgical resources and to determine the effect of hospital transfer on mortality.

ACS Style

Brenna S. Fullerton; Eric A. Sparks; Kate A. Morrow; Erika M. Edwards; Roger F. Soll; Tom Jaksic; Jeffrey D. Horbar; Biren P. Modi. Hospital transfers and patterns of mortality in very low birth weight neonates with surgical necrotizing enterocolitis. Journal of Pediatric Surgery 2016, 51, 932 -935.

AMA Style

Brenna S. Fullerton, Eric A. Sparks, Kate A. Morrow, Erika M. Edwards, Roger F. Soll, Tom Jaksic, Jeffrey D. Horbar, Biren P. Modi. Hospital transfers and patterns of mortality in very low birth weight neonates with surgical necrotizing enterocolitis. Journal of Pediatric Surgery. 2016; 51 (6):932-935.

Chicago/Turabian Style

Brenna S. Fullerton; Eric A. Sparks; Kate A. Morrow; Erika M. Edwards; Roger F. Soll; Tom Jaksic; Jeffrey D. Horbar; Biren P. Modi. 2016. "Hospital transfers and patterns of mortality in very low birth weight neonates with surgical necrotizing enterocolitis." Journal of Pediatric Surgery 51, no. 6: 932-935.

Journal article
Published: 22 January 2015 in Maternal Health, Neonatology and Perinatology
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Stabilization and resuscitation of a newborn infant is a complex activity that involves multiple team members. Neonatal intensive care units (NICU) participating in the Vermont Oxford Network (VON) iNICQ 2012 quality improvement collaborative reported on delivery room care policies and guidelines and submitted information on up to 10 consecutive deliveries attended by NICU team members. Teams received immediate feedback on their local performance and a summary of results from all participating units for use in quality improvement planning. Most of the 84 NICU teams that participated in the audit had policies or guidelines about which deliveries required NICU team attendance (83%), personnel who should attend (81%), and their required training (79%). Fewer had policies about briefing prior to the delivery (8%), debriefing after delivery (6%), or communicating with family members (10%). Eighty-one percent of NICUs reported using simulation-based resuscitation training, 14% used a safety checklist, and 2% videotaped deliveries for review. Of the 609 audited deliveries, 88% had team member attendance that conformed to unit policy, 66% had a briefing before delivery, 19% had a debriefing after delivery, and 92% had family communication occur within 30 minutes. NICU teams can improve the quality and safety of delivery room care by implementing formal tools designed to facilitate teamwork such as briefings, debriefings, checklists, and videotape reviews. Rapid online audits are effective methods for helping teams identify opportunities for improvement.

ACS Style

Erika M Edwards; Roger F Soll; Karla Ferrelli; Kate A Morrow; Gautham Suresh; Joanna Celenza; Jeffrey D Horbar. Identifying improvements for delivery room resuscitation management: results from a multicenter safety audit. Maternal Health, Neonatology and Perinatology 2015, 1, 2 .

AMA Style

Erika M Edwards, Roger F Soll, Karla Ferrelli, Kate A Morrow, Gautham Suresh, Joanna Celenza, Jeffrey D Horbar. Identifying improvements for delivery room resuscitation management: results from a multicenter safety audit. Maternal Health, Neonatology and Perinatology. 2015; 1 (1):2.

Chicago/Turabian Style

Erika M Edwards; Roger F Soll; Karla Ferrelli; Kate A Morrow; Gautham Suresh; Joanna Celenza; Jeffrey D Horbar. 2015. "Identifying improvements for delivery room resuscitation management: results from a multicenter safety audit." Maternal Health, Neonatology and Perinatology 1, no. 1: 2.

Multicenter study
Published: 01 December 2014 in Journal of Pediatric Surgery
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The distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type.VLBW neonates born 2009-2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA).48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%).This study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

ACS Style

Eric A. Sparks; Ivan M. Gutierrez; Jeremy G. Fisher; Faraz A. Khan; Kuang Horng Kang; Kate A. Morrow; Roger F. Soll; Erika M. Edwards; Jeffrey D. Horbar; Tom Jaksic; Biren P. Modi. Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis. Journal of Pediatric Surgery 2014, 49, 1821 -1824.e8.

AMA Style

Eric A. Sparks, Ivan M. Gutierrez, Jeremy G. Fisher, Faraz A. Khan, Kuang Horng Kang, Kate A. Morrow, Roger F. Soll, Erika M. Edwards, Jeffrey D. Horbar, Tom Jaksic, Biren P. Modi. Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis. Journal of Pediatric Surgery. 2014; 49 (12):1821-1824.e8.

Chicago/Turabian Style

Eric A. Sparks; Ivan M. Gutierrez; Jeremy G. Fisher; Faraz A. Khan; Kuang Horng Kang; Kate A. Morrow; Roger F. Soll; Erika M. Edwards; Jeffrey D. Horbar; Tom Jaksic; Biren P. Modi. 2014. "Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis." Journal of Pediatric Surgery 49, no. 12: 1821-1824.e8.

Multicenter study
Published: 22 June 2012 in BMC Pediatrics
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In 2006, the Vermont Oxford Network (VON) established the Neonatal Encephalopathy Registry (NER) to characterize infants born with neonatal encephalopathy, describe evaluations and medical treatments, monitor hypothermic therapy (HT) dissemination, define clinical research questions, and identify opportunities for improved care. Eligible infants were ≥ 36 weeks with seizures, altered consciousness (stupor, coma) during the first 72 hours of life, a 5 minute Apgar score of ≤ 3, or receiving HT. Infants with central nervous system birth defects were excluded. From 2006-2010, 95 centers registered 4232 infants. Of those, 59% suffered a seizure, 50% had a 5 minute Apgar score of ≤ 3, 38% received HT, and 18% had stupor/coma documented on neurologic exam. Some infants experienced more than one eligibility criterion. Only 53% had a cord gas obtained and only 63% had a blood gas obtained within 24 hours of birth, important components for determining HT eligibility. Sixty-four percent received ventilator support, 65% received anticonvulsants, 66% had a head MRI, 23% had a cranial CT, 67% had a full channel encephalogram (EEG) and 33% amplitude integrated EEG. Of all infants, 87% survived. The VON NER describes the heterogeneous population of infants with NE, the subset that received HT, their patterns of care, and outcomes. The optimal routine care of infants with neonatal encephalopathy is unknown. The registry method is well suited to identify opportunities for improvement in the care of infants affected by NE and study interventions such as HT as they are implemented in clinical practice.

ACS Style

Robert H Pfister; Peter Bingham; Erika M Edwards; Jeffrey D Horbar; Michael J Kenny; Terrie E Inder; Karin B Nelson; Tonse N K Raju; Roger F Soll. The Vermont oxford neonatal encephalopathy registry: rationale, methods, and initial results. BMC Pediatrics 2012, 12, 84 -84.

AMA Style

Robert H Pfister, Peter Bingham, Erika M Edwards, Jeffrey D Horbar, Michael J Kenny, Terrie E Inder, Karin B Nelson, Tonse N K Raju, Roger F Soll. The Vermont oxford neonatal encephalopathy registry: rationale, methods, and initial results. BMC Pediatrics. 2012; 12 (1):84-84.

Chicago/Turabian Style

Robert H Pfister; Peter Bingham; Erika M Edwards; Jeffrey D Horbar; Michael J Kenny; Terrie E Inder; Karin B Nelson; Tonse N K Raju; Roger F Soll. 2012. "The Vermont oxford neonatal encephalopathy registry: rationale, methods, and initial results." BMC Pediatrics 12, no. 1: 84-84.

Multicenter study
Published: 21 May 2012 in PEDIATRICS
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OBJECTIVE: To identify changes in mortality and neonatal morbidities for infants with birth weight 501 to 1500 g born from 2000 to 2009. METHODS: There were 355 806 infants weighing 501 to 1500 g who were born in 2000–2009. Mortality during initial hospitalization and major neonatal morbidity in survivors (early and late infection, chronic lung disease, necrotizing enterocolitis, severe retinopathy of prematurity, severe intraventricular hemorrhage, and periventricular leukomalacia) were assessed by using data from 669 North American hospitals in the Vermont Oxford Network. RESULTS: From 2000 to 2009, mortality for infants weighing 501 to 1500 g decreased from 14.3% to 12.4% (difference, −1.9%; 95% confidence interval, −2.3% to −1.5%). Major morbidity in survivors decreased from 46.4% to 41.4% (difference, −4.9%; 95% confidence interval, −5.6% to −4.2%). In 2009, mortality ranged from 36.6% for infants 501 to 750 g to 3.5% for infants 1251 to 1500 g, whereas major morbidity in survivors ranged from 82.7% to 18.7%. In 2009, 49.2% of all very low birth weight infants and 89.2% of infants 501 to 750 g either died or survived with a major neonatal morbidity. CONCLUSIONS: Mortality and major neonatal morbidity in survivors decreased for infants with birth weight 501 to 1500 g between 2000 and 2009. However, at the end of the decade, a high proportion of these infants still either died or survived after experiencing ≥1 major neonatal morbidity known to be associated with both short- and long-term adverse consequences.

ACS Style

Jeffrey D. Horbar; Joseph H. Carpenter; Gary J. Badger; Michael Kenny; Roger F. Soll; Kate A. Morrow; Jeffrey S. Buzas. Mortality and Neonatal Morbidity Among Infants 501 to 1500 Grams From 2000 to 2009. PEDIATRICS 2012, 129, 1019 -1026.

AMA Style

Jeffrey D. Horbar, Joseph H. Carpenter, Gary J. Badger, Michael Kenny, Roger F. Soll, Kate A. Morrow, Jeffrey S. Buzas. Mortality and Neonatal Morbidity Among Infants 501 to 1500 Grams From 2000 to 2009. PEDIATRICS. 2012; 129 (6):1019-1026.

Chicago/Turabian Style

Jeffrey D. Horbar; Joseph H. Carpenter; Gary J. Badger; Michael Kenny; Roger F. Soll; Kate A. Morrow; Jeffrey S. Buzas. 2012. "Mortality and Neonatal Morbidity Among Infants 501 to 1500 Grams From 2000 to 2009." PEDIATRICS 129, no. 6: 1019-1026.

Conference paper
Published: 01 January 2012 in Proceedings of the fourteenth international conference on Genetic and evolutionary computation conference companion - GECCO Companion '12
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ACS Style

Narine Manukyan; Margaret J. Eppstein; Jeffrey D. Horbar; Kathleen A. Leahy; Michael J. Kenny; Shreya Mukherjee; Donna M. Rizzo. Evolutionary mining for multivariate associations in large time-varying data sets. Proceedings of the fourteenth international conference on Genetic and evolutionary computation conference companion - GECCO Companion '12 2012, 1 .

AMA Style

Narine Manukyan, Margaret J. Eppstein, Jeffrey D. Horbar, Kathleen A. Leahy, Michael J. Kenny, Shreya Mukherjee, Donna M. Rizzo. Evolutionary mining for multivariate associations in large time-varying data sets. Proceedings of the fourteenth international conference on Genetic and evolutionary computation conference companion - GECCO Companion '12. 2012; ():1.

Chicago/Turabian Style

Narine Manukyan; Margaret J. Eppstein; Jeffrey D. Horbar; Kathleen A. Leahy; Michael J. Kenny; Shreya Mukherjee; Donna M. Rizzo. 2012. "Evolutionary mining for multivariate associations in large time-varying data sets." Proceedings of the fourteenth international conference on Genetic and evolutionary computation conference companion - GECCO Companion '12 , no. : 1.

Book chapter
Published: 01 January 2011 in Fanaroff and Martin's Neonatal–Perinatal Medicine
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ACS Style

Jalal M. Abu-Shaweesh; Veronica H. Accornero; Heidelise Als; Brenna L. Anderson; Jacob V. Aranda; James E. Arnold; Sundeep Arora; Komal Bajaj; Jill E. Baley; Eduardo H. Bancalari; Emmalee S. Bandstra; Edward M. Barksdale; Cynthia F. Bearer; Isaac Blickstein; Jeffrey L. Blumer; Samantha Butler; Kara Calkins; Michael S. Caplan; Waldemar A. Carlo; Gisela Chelimsky; Valerie Y. Chock; Walter J. Chwals; Alan R. Cohen; Daniel R. Cooperman; Timothy M. Crombleholme; Mario De Curtis; Linda S. De Vries; Katherine MacRae Dell; Scott Denne; Sherin U. Devaskar; Juliann Di Fiore; Steven M. Donn; Morven S. Edwards; William H. Edwards; Francine Erenberg; Avroy A. Fanaroff; Jonathan M. Fanaroff; Ross Fasano; Orna Flidel-Rimon; Smadar Friedman; Susan E. Gerber; Jay P. Goldsmith; Bernard Gonik; Jeffrey B. Gould; Pierre Gressens; Susan J. Gross; Andrée M. Gruslin; Balaji K. Gupta; Maureen Hack; Louis P. Halamek; Aaron Hamvas; Jonathan Hellmann; Susan R. Hintz; Steven B. Hoath; Jeffrey D. Horbar; McCallum R. Hoyt; Petra S. Huppi; Lucky Jain; Alan H. Jobe; Nancy E. Judge; Michael Kaplan; Satish C. Kalhan; Reuben Kapur; Ganga Karunamuni; Lawrence M. Kaufman; Kathleen A. Kennedy; John H. Kennell; Joseph A. Kitterman; Marshall H. Klaus; Robert M. Kliegman; Oded Langer; Noam Lazebnik; Malcolm I. Levene; Foong-Yen Lim; Tom Lissauer; Suzanne M. Lopez; Timothy E. Lotze; L.C. Naomi Luban; Lori Luchtman-Jones; David K. Magnuson; Henry H. Mangurten; Jacquelyn McClary; Geoffrey Miller; Marilyn T. Miller; Mohamed W. Mohamed; Thomas R. Moore; Colin J. Morley; Stuart C. Morrison; Anil Narang; Vivek Narendran; Mary L. Nock; Mark R. Palmert; Aditi S. Parikh; Robert L. Parry; Dale L. Phelps; Brenda Poindexter; Richard A. Polin; Bhagya L. Puppala; Tonse N.K. Raju; Ashwin Ramachandrappa; Raymond W. Redline; Jacques Rigo; Barrett K. Robinson; Susan R. Rose; Florence Rothenberg; Shaista Safder; Ola Didrik Saugstad; Katherine S. Schaefer; Mark S. Scher; Gunnar Sedin; Dinesh M. Shah; Eric S. Shinwell; Rayzel M. Shulman; Eric Sibley; Sunil K. Sinha; Carlos J. Sivit; Ernest S. Siwik; Robert C. Sprecher; Robin H. Steinhorn; David K. Stevenson; Eileen K. Stork; John E. Stork; Arjan B. Te Pas; George H. Thompson; Philip Toltzis; Robert Turbow; Jon E. Tyson; George F. Van Hare; Maximo Vento; Dharmapuri Vidyasagar; Beth A. Vogt; Betty Vohr; Michele C. Walsh; Michiko Watanabe; Diane K. Wherrett; Robert D. White; Georgia L. Wiesner; Jamie C. Wikenheiser; David B. Wilson; Deanne Wilson-Costello; Richard B. Wolf; Ronald J. Wong; Mervin C. Yoder; Thomas Young; Kenneth G. Zahka; Arthur B. Zinn. Contributors. Fanaroff and Martin's Neonatal–Perinatal Medicine 2011, 1 .

AMA Style

Jalal M. Abu-Shaweesh, Veronica H. Accornero, Heidelise Als, Brenna L. Anderson, Jacob V. Aranda, James E. Arnold, Sundeep Arora, Komal Bajaj, Jill E. Baley, Eduardo H. Bancalari, Emmalee S. Bandstra, Edward M. Barksdale, Cynthia F. Bearer, Isaac Blickstein, Jeffrey L. Blumer, Samantha Butler, Kara Calkins, Michael S. Caplan, Waldemar A. Carlo, Gisela Chelimsky, Valerie Y. Chock, Walter J. Chwals, Alan R. Cohen, Daniel R. Cooperman, Timothy M. Crombleholme, Mario De Curtis, Linda S. De Vries, Katherine MacRae Dell, Scott Denne, Sherin U. Devaskar, Juliann Di Fiore, Steven M. Donn, Morven S. Edwards, William H. Edwards, Francine Erenberg, Avroy A. Fanaroff, Jonathan M. Fanaroff, Ross Fasano, Orna Flidel-Rimon, Smadar Friedman, Susan E. Gerber, Jay P. Goldsmith, Bernard Gonik, Jeffrey B. Gould, Pierre Gressens, Susan J. Gross, Andrée M. Gruslin, Balaji K. Gupta, Maureen Hack, Louis P. Halamek, Aaron Hamvas, Jonathan Hellmann, Susan R. Hintz, Steven B. Hoath, Jeffrey D. Horbar, McCallum R. Hoyt, Petra S. Huppi, Lucky Jain, Alan H. Jobe, Nancy E. Judge, Michael Kaplan, Satish C. Kalhan, Reuben Kapur, Ganga Karunamuni, Lawrence M. Kaufman, Kathleen A. Kennedy, John H. Kennell, Joseph A. Kitterman, Marshall H. Klaus, Robert M. Kliegman, Oded Langer, Noam Lazebnik, Malcolm I. Levene, Foong-Yen Lim, Tom Lissauer, Suzanne M. Lopez, Timothy E. Lotze, L.C. Naomi Luban, Lori Luchtman-Jones, David K. Magnuson, Henry H. Mangurten, Jacquelyn McClary, Geoffrey Miller, Marilyn T. Miller, Mohamed W. Mohamed, Thomas R. Moore, Colin J. Morley, Stuart C. Morrison, Anil Narang, Vivek Narendran, Mary L. Nock, Mark R. Palmert, Aditi S. Parikh, Robert L. Parry, Dale L. Phelps, Brenda Poindexter, Richard A. Polin, Bhagya L. Puppala, Tonse N.K. Raju, Ashwin Ramachandrappa, Raymond W. Redline, Jacques Rigo, Barrett K. Robinson, Susan R. Rose, Florence Rothenberg, Shaista Safder, Ola Didrik Saugstad, Katherine S. Schaefer, Mark S. Scher, Gunnar Sedin, Dinesh M. Shah, Eric S. Shinwell, Rayzel M. Shulman, Eric Sibley, Sunil K. Sinha, Carlos J. Sivit, Ernest S. Siwik, Robert C. Sprecher, Robin H. Steinhorn, David K. Stevenson, Eileen K. Stork, John E. Stork, Arjan B. Te Pas, George H. Thompson, Philip Toltzis, Robert Turbow, Jon E. Tyson, George F. Van Hare, Maximo Vento, Dharmapuri Vidyasagar, Beth A. Vogt, Betty Vohr, Michele C. Walsh, Michiko Watanabe, Diane K. Wherrett, Robert D. White, Georgia L. Wiesner, Jamie C. Wikenheiser, David B. Wilson, Deanne Wilson-Costello, Richard B. Wolf, Ronald J. Wong, Mervin C. Yoder, Thomas Young, Kenneth G. Zahka, Arthur B. Zinn. Contributors. Fanaroff and Martin's Neonatal–Perinatal Medicine. 2011; ():1.

Chicago/Turabian Style

Jalal M. Abu-Shaweesh; Veronica H. Accornero; Heidelise Als; Brenna L. Anderson; Jacob V. Aranda; James E. Arnold; Sundeep Arora; Komal Bajaj; Jill E. Baley; Eduardo H. Bancalari; Emmalee S. Bandstra; Edward M. Barksdale; Cynthia F. Bearer; Isaac Blickstein; Jeffrey L. Blumer; Samantha Butler; Kara Calkins; Michael S. Caplan; Waldemar A. Carlo; Gisela Chelimsky; Valerie Y. Chock; Walter J. Chwals; Alan R. Cohen; Daniel R. Cooperman; Timothy M. Crombleholme; Mario De Curtis; Linda S. De Vries; Katherine MacRae Dell; Scott Denne; Sherin U. Devaskar; Juliann Di Fiore; Steven M. Donn; Morven S. Edwards; William H. Edwards; Francine Erenberg; Avroy A. Fanaroff; Jonathan M. Fanaroff; Ross Fasano; Orna Flidel-Rimon; Smadar Friedman; Susan E. Gerber; Jay P. Goldsmith; Bernard Gonik; Jeffrey B. Gould; Pierre Gressens; Susan J. Gross; Andrée M. Gruslin; Balaji K. Gupta; Maureen Hack; Louis P. Halamek; Aaron Hamvas; Jonathan Hellmann; Susan R. Hintz; Steven B. Hoath; Jeffrey D. Horbar; McCallum R. Hoyt; Petra S. Huppi; Lucky Jain; Alan H. Jobe; Nancy E. Judge; Michael Kaplan; Satish C. Kalhan; Reuben Kapur; Ganga Karunamuni; Lawrence M. Kaufman; Kathleen A. Kennedy; John H. Kennell; Joseph A. Kitterman; Marshall H. Klaus; Robert M. Kliegman; Oded Langer; Noam Lazebnik; Malcolm I. Levene; Foong-Yen Lim; Tom Lissauer; Suzanne M. Lopez; Timothy E. Lotze; L.C. Naomi Luban; Lori Luchtman-Jones; David K. Magnuson; Henry H. Mangurten; Jacquelyn McClary; Geoffrey Miller; Marilyn T. Miller; Mohamed W. Mohamed; Thomas R. Moore; Colin J. Morley; Stuart C. Morrison; Anil Narang; Vivek Narendran; Mary L. Nock; Mark R. Palmert; Aditi S. Parikh; Robert L. Parry; Dale L. Phelps; Brenda Poindexter; Richard A. Polin; Bhagya L. Puppala; Tonse N.K. Raju; Ashwin Ramachandrappa; Raymond W. Redline; Jacques Rigo; Barrett K. Robinson; Susan R. Rose; Florence Rothenberg; Shaista Safder; Ola Didrik Saugstad; Katherine S. Schaefer; Mark S. Scher; Gunnar Sedin; Dinesh M. Shah; Eric S. Shinwell; Rayzel M. Shulman; Eric Sibley; Sunil K. Sinha; Carlos J. Sivit; Ernest S. Siwik; Robert C. Sprecher; Robin H. Steinhorn; David K. Stevenson; Eileen K. Stork; John E. Stork; Arjan B. Te Pas; George H. Thompson; Philip Toltzis; Robert Turbow; Jon E. Tyson; George F. Van Hare; Maximo Vento; Dharmapuri Vidyasagar; Beth A. Vogt; Betty Vohr; Michele C. Walsh; Michiko Watanabe; Diane K. Wherrett; Robert D. White; Georgia L. Wiesner; Jamie C. Wikenheiser; David B. Wilson; Deanne Wilson-Costello; Richard B. Wolf; Ronald J. Wong; Mervin C. Yoder; Thomas Young; Kenneth G. Zahka; Arthur B. Zinn. 2011. "Contributors." Fanaroff and Martin's Neonatal–Perinatal Medicine , no. : 1.

Review article
Published: 31 March 2010 in Clinics in Perinatology
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The Vermont Oxford Network is a not-for-profit organization established in the late 1980s with the goals of improving the quality and safety of medical care for newborn infants and their families through a coordinated program of research, education, and quality improvement. In this paper the authors discuss the activities and programs sponsored by the Network to achieve those goals.

ACS Style

Jeffrey D. Horbar; Roger F. Soll; William H. Edwards. The Vermont Oxford Network: A Community of Practice. Clinics in Perinatology 2010, 37, 29 -47.

AMA Style

Jeffrey D. Horbar, Roger F. Soll, William H. Edwards. The Vermont Oxford Network: A Community of Practice. Clinics in Perinatology. 2010; 37 (1):29-47.

Chicago/Turabian Style

Jeffrey D. Horbar; Roger F. Soll; William H. Edwards. 2010. "The Vermont Oxford Network: A Community of Practice." Clinics in Perinatology 37, no. 1: 29-47.

Journal article
Published: 01 November 2006 in PEDIATRICS
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ACS Style

Jeffrey D. Horbar; Paul E. Plsek; Janice A. Schriefer; Kathy Leahy; L'huillier A; V. Dmitra\v Sinovi\' C; Nnp. Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The Neonatal Intensive Care Quality Improvement Collaborative Experience: FIGURE 1. PEDIATRICS 2006, 118, S57 -S64.

AMA Style

Jeffrey D. Horbar, Paul E. Plsek, Janice A. Schriefer, Kathy Leahy, L'huillier A, V. Dmitra\v Sinovi\' C, Nnp. Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The Neonatal Intensive Care Quality Improvement Collaborative Experience: FIGURE 1. PEDIATRICS. 2006; 118 (Supplement):S57-S64.

Chicago/Turabian Style

Jeffrey D. Horbar; Paul E. Plsek; Janice A. Schriefer; Kathy Leahy; L'huillier A; V. Dmitra\v Sinovi\' C; Nnp. 2006. "Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The Neonatal Intensive Care Quality Improvement Collaborative Experience: FIGURE 1." PEDIATRICS 118, no. Supplement: S57-S64.

Journal article
Published: 01 May 2005 in The ANNALS of the American Academy of Political and Social Science
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This article makes a case for cluster-randomized trials to encourage evidence-based practice in medical care. The case rests on theoretical, empirical, and methodological grounds. To illustrate, we describe two recent studies. The first trial, with participation by 27 tertiary care hospitals, concerned methods to encourage a relatively simple, low-cost therapy for women in premature labor. A significant effect was seen in intervention hospitals on the primary outcome variable: increase in the proportion of eligible patients receiving antenatal corticosteroid therapy. The second trial, with participation by 114 neonatal intensive care units, aimed to close the gap between evidence and practice in the use of early and prophylactic surfactant therapy for premature infants. It achieved one of the largest effects seen in the literature on changing medical care practices. Using the two illustrations, the authors discuss some of the theoretical, methodological, and practical issues when using cluster randomized designs in this field of inquiry.

ACS Style

Laura C. Leviton; Jeffrey D. Horbar. Cluster Randomized Trials for the Evaluation of Strategies Designed to Promote Evidence-Based Practice in Perinatal and Neonatal Medicine. The ANNALS of the American Academy of Political and Social Science 2005, 599, 94 -114.

AMA Style

Laura C. Leviton, Jeffrey D. Horbar. Cluster Randomized Trials for the Evaluation of Strategies Designed to Promote Evidence-Based Practice in Perinatal and Neonatal Medicine. The ANNALS of the American Academy of Political and Social Science. 2005; 599 (1):94-114.

Chicago/Turabian Style

Laura C. Leviton; Jeffrey D. Horbar. 2005. "Cluster Randomized Trials for the Evaluation of Strategies Designed to Promote Evidence-Based Practice in Perinatal and Neonatal Medicine." The ANNALS of the American Academy of Political and Social Science 599, no. 1: 94-114.

Clinical trial
Published: 28 October 2004 in BMJ
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Objective To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. Design Cluster randomised controlled trial Setting and participants 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). Main outcome measures Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. Intervention Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. Results Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. Conclusion A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

ACS Style

Jeffrey D Horbar; Joseph H Carpenter; Jeffrey Buzas; Roger F Soll; Gautham Suresh; Michael B Bracken; Laura C Leviton; Paul E Plsek; John C Sinclair. Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial. BMJ 2004, 329, 1004 -1004.

AMA Style

Jeffrey D Horbar, Joseph H Carpenter, Jeffrey Buzas, Roger F Soll, Gautham Suresh, Michael B Bracken, Laura C Leviton, Paul E Plsek, John C Sinclair. Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial. BMJ. 2004; 329 (7473):1004-1004.

Chicago/Turabian Style

Jeffrey D Horbar; Joseph H Carpenter; Jeffrey Buzas; Roger F Soll; Gautham Suresh; Michael B Bracken; Laura C Leviton; Paul E Plsek; John C Sinclair. 2004. "Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial." BMJ 329, no. 7473: 1004-1004.

Comparative study
Published: 01 June 2004 in Pediatrics
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To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines. Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed. A total of 47 608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%-75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%-34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found. Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks' gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.

ACS Style

J. D. Horbar; J. H. Carpenter; J. Buzás; R. F. Soll; G. Suresh; M. B. Bracken; L. C. Leviton; P. E. Plsek; J. C. Sinclair. Timing of Initial Surfactant Treatment for Infants 23 to 29 Weeks' Gestation: Is Routine Practice Evidence Based? Pediatrics 2004, 113, 1593 -1602.

AMA Style

J. D. Horbar, J. H. Carpenter, J. Buzás, R. F. Soll, G. Suresh, M. B. Bracken, L. C. Leviton, P. E. Plsek, J. C. Sinclair. Timing of Initial Surfactant Treatment for Infants 23 to 29 Weeks' Gestation: Is Routine Practice Evidence Based? Pediatrics. 2004; 113 (6):1593-1602.

Chicago/Turabian Style

J. D. Horbar; J. H. Carpenter; J. Buzás; R. F. Soll; G. Suresh; M. B. Bracken; L. C. Leviton; P. E. Plsek; J. C. Sinclair. 2004. "Timing of Initial Surfactant Treatment for Infants 23 to 29 Weeks' Gestation: Is Routine Practice Evidence Based?" Pediatrics 113, no. 6: 1593-1602.

Obstetrics
Published: 01 June 2004 in Obstetrical & Gynecological Survey
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An increasing number of insurers today rely on evidence-based selective referral strategies to be sure that care is delivered by high-quality providers. Lacking direct-quality measures based on patient outcomes, current standards for many conditions are based on indirect quality measures such as patient volume. This retrospective study was designed to show whether volume is a useful quality indicator for the care of very-low-birth-weight (VLBW) infants. The study population consisted of 94,110 VLBW infants weighing 501 to 1500 g who were born at 332 U.S. hospitals having neonatal intensive-care units in the years 1995–2000. The average hospital admitted approximately 80 VLBW infants each year, but 25% admitted fewer than 40 per year and 10% admitted fewer than 25. The hospitals, in general, provided a high level of care; most had either a level B or a level C neonatal intensive-care unit. At hospitals admitting fewer than 50 VLBW infants, considered low-volume hospitals, an additional 10 admissions correlated with an 11% reduction in mortality (95% confidence interval [CI], 5–16%; P < 0.001). The annual number of admissions explained only 9% of the variation in mortality rates at the participating hospitals. Other easily available hospital features explained another 7% of variation. Because historical volume did not relate significantly to mortality rates in 1999–2000, case volume did not prospectively identify high-quality providers. In contrast, hospitals in the lowest mortality quintile in 1995–1998 had significantly lower mortality rates in 1999–2000 (odds ratio [OR], 0.64; 95% CI, 0.55–0.76). In addition, hospitals in the highest mortality quintile had significantly higher mortality in 1999–2000 (OR, 1.37; 95% CI, 1.16–1.64). Whereas the highest and lowest mortality quintiles explained 34% of between-hospital variation in mortality in 1999–2000, the corresponding figure for the highest and lowest quintiles of patient volume was only 1%. These findings bring into question the referral of VLBW infants based on indirect quality indicators such as patient volume. Direct measures based on outcomes are more useful in guiding selective referral.

ACS Style

Jeannette A. Rogowski; Jeffrey D. Horbar; Douglas O. Staiger; Michael Kenny; Joseph Carpenter; Jeffrey Geppert. Indirect vs. Direct Hospital Quality Indicators for Very-Low-Birth-Weight Infants. Obstetrical & Gynecological Survey 2004, 59, 424 -425.

AMA Style

Jeannette A. Rogowski, Jeffrey D. Horbar, Douglas O. Staiger, Michael Kenny, Joseph Carpenter, Jeffrey Geppert. Indirect vs. Direct Hospital Quality Indicators for Very-Low-Birth-Weight Infants. Obstetrical & Gynecological Survey. 2004; 59 (6):424-425.

Chicago/Turabian Style

Jeannette A. Rogowski; Jeffrey D. Horbar; Douglas O. Staiger; Michael Kenny; Joseph Carpenter; Jeffrey Geppert. 2004. "Indirect vs. Direct Hospital Quality Indicators for Very-Low-Birth-Weight Infants." Obstetrical & Gynecological Survey 59, no. 6: 424-425.

Multicenter study
Published: 14 January 2004 in JAMA
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Evidence-based selective referral strategies are being used by an increasing number of insurers to ensure that medical care is provided by high-quality providers. In the absence of direct-quality measures based on patient outcomes, the standards currently in place for many conditions rely on indirect-quality measures such as patient volume.

ACS Style

Jeannette A. Rogowski; Jeffrey D. Horbar; Uglas O. Staiger; Michael Kenny; Joseph Carpenter; Jeffrey Geppert. Indirect vs Direct Hospital Quality Indicators for Very Low-Birth-Weight Infants. JAMA 2004, 291, 202 .

AMA Style

Jeannette A. Rogowski, Jeffrey D. Horbar, Uglas O. Staiger, Michael Kenny, Joseph Carpenter, Jeffrey Geppert. Indirect vs Direct Hospital Quality Indicators for Very Low-Birth-Weight Infants. JAMA. 2004; 291 (2):202.

Chicago/Turabian Style

Jeannette A. Rogowski; Jeffrey D. Horbar; Uglas O. Staiger; Michael Kenny; Joseph Carpenter; Jeffrey Geppert. 2004. "Indirect vs Direct Hospital Quality Indicators for Very Low-Birth-Weight Infants." JAMA 291, no. 2: 202.

Multicenter study
Published: 01 April 2003 in Pediatrics
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ACS Style

Jeffrey D Horbar; Paul E Plsek; Kathy Leahy. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics 2003, 111, 1 .

AMA Style

Jeffrey D Horbar, Paul E Plsek, Kathy Leahy. NIC/Q 2000: establishing habits for improvement in neonatal intensive care units. Pediatrics. 2003; 111 (4):1.

Chicago/Turabian Style

Jeffrey D Horbar; Paul E Plsek; Kathy Leahy. 2003. "NIC/Q 2000: establishing habits for improvement in neonatal intensive care units." Pediatrics 111, no. 4: 1.