J. Pediatr. (Rio J.) vol.91 número3

JPediatr(RioJ).2015;91(3):207---209

www.jped.com.br

EDITORIAL

The

importance

of

understanding

hospital

and

country-specific

case-mix

for

neonatal

patients

夽

,

夽夽

A

importância

de

entender

o

case-mix

_de

_pacientes

_neonatais

_em

_hospitais

e

específicos

de

um

país

Scott

A.

Lorch

a_{DepartmentofPediatrics,TheChildren’sHospitalofPhiladelphia,Philadelphia,UnitedStates} b_{PerelmanSchoolofMedicine,UniversityofPennsylvania,Philadelphia,UnitedStates}

c_{CenterforOutcomesResearch,TheChildren’sHospitalofPhiladelphia,Philadelphia,UnitedStates}

d_{CenterforPerinatalandPediatricHealthDisparitiesResearch,TheChildren’sHospitalofPhiladelphia,Philadelphia,}

UnitedStates

e_{LeonardDavisInstituteofHealthEconomics,UniversityofPennsylvania,Philadelphia,UnitedStates}

Thestudy byGrandietal.providesimportantinformation abouttheprevalenceandimpactofmaternaldiabetes mel-litus onthe outcomes of very low birth weightinfants in SouthAmericanneonatalintensivecareunits(NICUs).They reportan overall rateof maternal diabetes of 2.8%, with an increasein prevalencefrom2001-2005 of2.4% to3.2% overtheperiodbetween2006-2010.Also,ofthenumerous perinatal andneonatal outcomesexamined in this cohort ofalmost12,000infants,onlyseverenecrotizing enterocol-itis wasassociatedwithdiabetesmellitus inmultivariable regression.1_{Thesedatadifferfromotherpublishedresults.}

Priorstudiesoftheprevalenceofgestationaldiabetesrange fromanestimated2-6%ofcasesacrossEuropeancountries,2

5-11%within15statesoftheUS,3_{and16%inQatar.}4_Several

studies fromboth low- andmiddle-income countries5 _and

developed countries6 _{also show diabetes as a risk factor}

DOIoforiginalarticle:

http://dx.doi.org/10.1016/j.jped.2014.08.007

夽 _{Please cite this article as: Lorch SA. The importance of}

understandinghospitalandcountry-specificcase-mixforneonatal patients.JPediatr(RioJ).2015;91:207---9.

夽夽

SeepaperbyGrandietal.inpages234---41.

E-mail:lorch@email.chop.edu

for adverse pregnancy and neonatal outcomes, albeit in the entire population versus a specific, high-risk popula-tionsuchasthatstudied byGrandi etal.1 _Whatdothese

findings,or anysimilarfindings,meanforthecliniciansor policy makers overseeing the care delivered to high-risk newborns,especiallyinlightofdatasuggestingthatratesof gestationaldiabetesinothercountriesisincreasing?7

Prac-titionersshouldassessthevalidityofthe resultsandthen determine the potential impact of these results on their practice.

Foranystudy,weshouldexaminewhetherthedataare accuratebeforeany actions areundertaken. Inaccuracies canoccurinthreemajorareas:2_{couldthediagnosisbemade}

inallwomen;wasthediagnostictestappropriate;andwere thedatacollectedoneachpregnancycorrect.Fora condi-tionsuchasgestationaldiabetes,womenmustbothreceive prenatalcare,andhavethetesttoconfirmeitherthe pres-enceorabsenceofthecondition.Dependingonthehospital, health system, or country’s population andsocial dynam-ics,accesstoprenatalcareortothetoolsneededtomake thediagnosismaybelimited.Additionally,fordiabetes,one standarddiagnosticprocedureisa1-or3-hourglucosetest, administeredtypically at 24-28 weeks gestation.It is not clearwhatpercentageofwomenwhodeliveredbefore28 weeksgestation couldhave had thediagnosis. These two

http://dx.doi.org/10.1016/j.jped.2015.01.003

208 LorchSA

situationscouldhavelowerthereportedrateofdiabetesin thisoranyothersimilarstudy.

Secondly, it is important that the correct diagnostic testis used.Priorstudies useddifferentteststodiagnose diabetes.2_{ThisstudygroupspecificallysuggestedtheWorld}

HealthOrganization oral glucosetolerance test,but notes that,withdata collectionacross multiple centersin mul-tiplecountries,thiscriterionwasnotuniversallyfollowed. However,the fact that specific tests were encouraged at each center is a positive aspect of the data collection. Finally, largerpopulation-based datasets may notcontain thecorrectinformationonallpatients.Forexample, mor-talityratesmaydifferdependingonthedatasource,8_likely

becauseofdifferencesintheaccuracyoftherecordeddata, depending onwhether registry or vitalstatistics data are used.Theuseofadetailedregistryofpatientssuchasthat oftheNeocosurNetwork,withbuiltinmethodstovalidate the recorded data, improves the reported results. All of theseissuesmayresultininter-hospitalvariationsinhealth outcomesthathavenothingtodowiththecaredelivered, butratherdifferencesintheaccuracyofthedataor differ-encesin thepatients includedin themeasurement inthe firstplace.9_{Withthedatastructuresinplace,theaccuracy}

ofthesedataarelikelyasstrong astheycan be,without modifying clinical practices at each individual hospital ---somethingthatischallengingtodoacrossmultiplehospital systemsinmultiplecountries.

After assessing the validityof the data, such reported variationindiabetesmellitusprevalenceandimpacton out-come then supports the idea that clinicians should know the patients that they care for, especially in areas that differfromthoseareas wheremanyof thereported stud-ies occurred. First, the lower prevalence of diabetes in theNICUsofthese22hospitalsmayaffectdecisionsabout additional screening of women or quality improvement and education programs to address either the diagnosis or treatment of diabetes in theseunits. Second, thefact thatdiabeteswasnotassociatedwithadverseoutcomesin thesepatientssupportsotherworkshowingthattreatments may have different effects on patient health depending on the geographic setting they are delivered. For exam-ple, numerous studies from the developed world show the beneficial effect of antenatal corticosteroids on the disease-free survival of high-risk infants. A recent clus-terrandomizedtrialofcorticosteroidadministrationinsix low-andmiddle-incomecountries (Argentina,Guatemala, India,Kenya,Pakistan,andZambia),though,found neona-talmortalitydidnotdecreaseinlowbirthweightinfants, withincreased neonatalmortality and maternal infection riskoverallintheclustersrandomizedtoprocessesofcare designedtoincreaseuseofantenatalcorticosteroids.10_This

difference may have occurred because of differences in thebaselinematernalhealthinthesesixcountriesandthe different health resources available to care for high-risk children in these countries compared to the pregnancies included in previous studies from the developed world.11

However, there can also be variations in the effect of a specific treatment within a singlecountry. The impactof delivery at a high-volume, high-level neonatal intensive care unitdifferedacross threestates in theUS, withthe survivalbenefitrangingfrom30%to330%dependingonthe state. Similar differences were seen in the reduction of

commoncomplicationsofpretermbirth.12_{Thethreestates}

differed in the distribution of racial/ethnic backgrounds, health insurancestatus,andprevalence ofmany antepar-tum complications of pregnancy. Thus, different patient populations may have differentmedical and geneticrisks ofdisease.However,theseregionsalsodifferinthe orga-nizationofperinatalcare,withdifferentprocessesofcare withregardtomaternalandinfanttransportsystems, cen-tralizationofperinatalservices,andregionalizationofcare. These examples illustrate differences the casemix of individualhospitals,andhowtheeffectof common treat-ments may differ depending on this casemix. It is likely, though, that thepatients included in theseabove studies andthestudybyGrandietal.alsodifferedinsocialfactors suchashousing,education,andincome. Whilenotas fre-quently measuredinperinatalandneonatalstudies,these ‘‘social determinants of health’’ may influence both the prevalenceofdiseasessuchasdiabetesandalsotheultimate outcomeoftheseconditions.LatinAmericaisnotimmune fromthese adverse socialdeterminants,13 _{and infact the}

parallel private/publicsystems that arecommon in many LatinAmericancountriesmaydifferfromthosesystemsthat care for patients in many studies of neonatalhealth and treatment.14 _{More researchneeds tofocus on how these}

factors affect the health andoutcomes of thesehigh-risk patients.

In summary, the study by Grandi et al. illustrates the importance of understanding the patients cared for by healthcaregroups,whetherhospitals,states,orcountries, and how they respond to specific treatments. Practition-ers discuss personalized medicine, where treatments are given depending on a patient’s genetic, medical, and social background. We should think about how different patient populations have different risks of disease that require subtle changes to management plans in order to optimize patient outcomes. Understanding of these best practices is needed to optimize perinatal and neonatal health.

Conflicts

of

interest

Theauthordeclaresnoconflictsofinterest.

References

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3.DeSistoCL,KimSY,SharmaAJ. Prevalenceestimatesof ges-tational diabetes mellitus in the United States. Pregnancy RiskAssessmentMonitoringSystem(PRAMS), 2007-2010.Prev ChronicDis.2014;11:E104.

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11.CostelloA,AzadK.Scalingupantenatalcorticosteroidsin low-resourcesettings?Lancet.2014,pii:S0140-6736(14)61699-8.

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