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261 Risk Scoring System for Preterm Birth: Prospective Assessment and Added Value of Psychosocial and Demographic Variables
SPO Abstracts
Volume 168 1\'utnber l, Part 2
260 TOTAL AND INCREMENTAL COST OF PREMATURIlY
James S. Smeltzer, M.D., Elaine Sneed" Jaye M. Shyken, M.D. Department of Obstetrics and Gynecology, Washington Univ., Gencare Sanus, General American Life, St. Louis MO OBJECTIVES: We calculated the average cost per case and incremental cost per day for neonatal intensive care due to prematurity, in order to design a premature birth prevention program in a managed care group. STUDY DESIGN: Neonatal intensive care charges to a single large midwestern urban managed care group for premature deliveries from Jan 1990 through April 92 from were evaluated. Total cost of neonatal intensive care, and decremental cost per week gestational age gained over 24 weeks were calculated, the former by simple division, and the latter by multi-phase linear regression (NCSS, Kaysville UT). RESULTS: Thirty-one infants required neonatal intensive carc. One infant with congenital anomalies was excluded. Thirty remaining infants cost $1002 per delivery during the period. Gestational age was found to account for 84 percent of all variation in NICU costs. From 24 to 29.6 weeks, Cost = $983,045 - $31,622 (± $5,530 SER) times weeks gestation. From 29.6 to 35 weeks, Cost = $202,593 - $5,231 • weeks gestation (p<.OOOl). CONCLUSIONS: In this population, neonatal intensive care costs of prematurity were significant, and were strongly related to gestatIonal age. A cost-effective prevention program for all pregnant women would cost less than $1,002 times the percent efficacy of the program. A cost-effective treatment program would cost less than $31,622 per expected week gained prior to 30 weeks, and $5,231 per expected week gained after 30 weeks, which should be doubled for twin pregnancies. No significant cost reduction for NICU care occurs beyond 35 weeks. A costeffective prematurity prevention program can include high-cost interventions, such as mandated referral for targeted specialized management of high risk groups such as twins.
261
RISK SCORING SYSTEM FOR PRETERM BIRTH: PROSPECTIVE ASSESSMENT AND ADDED VALUE OF PSYCHOSOCIAL AND DEMOGRAPHIC VARIABLES. MG Ross, M Sandhu x, R Bemis x , S NessirnX, JR Bragonier X , CJ Hobel. Dept. Ob/Gyn, Harbor-UCLA and Cedars Sinai Med. Ctrs., Torrance and Los Angeles, CA. OBJECTIVE: Few prematurity risk scoring systems have been rigorously tested prospectively. Using a retrospective data-base, we previously reported a simplified risk scoring (SRS) system for preterm birth among a predominantly Hispanic population. 1 We sought to: 1) validate the SRS in a prospective study, not Influenced by patients' risk status and 2) enhance the SRS system with additional psychosocial and demographic variables. At the first prenatal visit, patients in the STUDY DESIGN: control sites of the Los Angeles Prematurity Prevention Project received double blinded risk assessment and a psychosocial questionnaire. Delivery results and risk factor associations were assessed by mutt i-variate regression. RESULTS: Prospective analysis of the SRS resulted in a sensitivity of 43.8% and a specificity of 72.7% with 28% high risk patients, as compared to a predicted sensitivity of 55.6%, specificity of 68.4%, and 33% high risk. Three additional questionnaire variables were associated with preterm birth (race, ~2 preschool children, moving during pregnancy). When these factors were combined with the SRS score, and controlling for the observed sensitivity of 43.8%, the specificity significantly improved to 77.0% (p=0.001; 22% high risk). CONCLUSIONS: Risk scoring systems for prematurity may be significantly improved with the addition of psychosocial and demographic factors. 1 Ross et ai, Am J Perinatology, 1986; 3:339-344. Supported by CA Dept of Health Service, MCH Branch. Analyses and conclusions are those of the authors and not the State of CA.
262 PREIERM
LABOR: THE EFFECT OF RECENT SUBSTANCE USE ON THE OCCURRENCE OFPREIERM DELIVERY. JT Christmas, PH McGhee', MJ Dinsmoor, SJ Irons', KS Dawson', CW Kish'. Depts. OB/GYN & Biostatistics, VA Commonwealth University!Med. Col. VA, Richmond, VA OBJECTIVE: To evaluate the effect of recent substance use on (PTD) in patients with preterm labor (P1L). SIUDY DESIGN: Patients in P1L with toxicologic evidence of recent substance use (S+) were compared to those without (S-). The groups were analyzed with respect to risk factors for PTD including maternal age, race, gestational age and cervical dilatation at admission. P1L management was identical. RESULTS: Of 51 patients admitted in P1L, 23 (45%) had evidence of recent substance use. The most common substance detected was cocaine (16 of 23; 70%). There was no difference between the groups in maternal age, race, or gestational age at admission. S+ patients were more likely to have PTD within 48 hours of admission (19 of 23 vs 13 of 28; p<.02). This difference persisted after correction for differences in cervical dilatation at admission. CONCLUSION: Substance use increases the risk of PTD in patients presenting with P1L independent of dilatation at the time of admission. Supported by NIDA grant # DA 0609-04. All pts. Dil ~2cm Oil >2cm ~48 >48 ~48 >48 ~48 >48
:~ I: I': I ffiij
263
tHE
p=02
EPISIOTOMY DOES NOT PROTECT AGAINST INTRAVENTRICULAR HEMORRHAGE IN THE VERY LOW BIRTHWEIGHT.NEONATE. D Platel2', C Chazotte, x M Schulman Depts. Ob/Gyn & Peds, Albert Einstein Coli of Med, Bronx Municipal Hosp Ctr, Bronx, NY OBJECTIVE: To determine if routine episiotomy (EP) protects against the development of intraventricular hemorrhage (IVH) in the preterm infant. STUDY DESIGN: A review of delivery mode, presence of IVH, and early neonatal course of all infants weighing 501-1500 gms delivered between 1984-91 who had a head ultrasound within 72 hours of birth. Excluded were infants who were small for gestational age, anomalous, and those delivered vaginally with breech presentations. RESULTS: Of 205 who infants met the above criteria, there were no significant differences in the parity, birth wt, incidence or severity of IVH between the groups: No EP EP CS n=60 n=52 n=93 IVH present 16 (26.7%) 15 (28.8%) 23 (24.7%) Birth Wt (g) 1110.3 1125.4 1124.2 Wt <1000g 23 (38.3%) 18 (34.6%) 27 (29.0%) Confounding variables, degree of resuscitation, neonatal hypotension, development of pneumothorax, and neonatal thrombocytopenia within 72 hrs, were equally distributed among the 3 groups. CONCLUSION: This study suggests that prophylactic episiotomy does not decrease the incidence of early IVH in the very low birthweight infant.
371
Volume 168 1\'utnber l, Part 2
260 TOTAL AND INCREMENTAL COST OF PREMATURIlY
James S. Smeltzer, M.D., Elaine Sneed" Jaye M. Shyken, M.D. Department of Obstetrics and Gynecology, Washington Univ., Gencare Sanus, General American Life, St. Louis MO OBJECTIVES: We calculated the average cost per case and incremental cost per day for neonatal intensive care due to prematurity, in order to design a premature birth prevention program in a managed care group. STUDY DESIGN: Neonatal intensive care charges to a single large midwestern urban managed care group for premature deliveries from Jan 1990 through April 92 from were evaluated. Total cost of neonatal intensive care, and decremental cost per week gestational age gained over 24 weeks were calculated, the former by simple division, and the latter by multi-phase linear regression (NCSS, Kaysville UT). RESULTS: Thirty-one infants required neonatal intensive carc. One infant with congenital anomalies was excluded. Thirty remaining infants cost $1002 per delivery during the period. Gestational age was found to account for 84 percent of all variation in NICU costs. From 24 to 29.6 weeks, Cost = $983,045 - $31,622 (± $5,530 SER) times weeks gestation. From 29.6 to 35 weeks, Cost = $202,593 - $5,231 • weeks gestation (p<.OOOl). CONCLUSIONS: In this population, neonatal intensive care costs of prematurity were significant, and were strongly related to gestatIonal age. A cost-effective prevention program for all pregnant women would cost less than $1,002 times the percent efficacy of the program. A cost-effective treatment program would cost less than $31,622 per expected week gained prior to 30 weeks, and $5,231 per expected week gained after 30 weeks, which should be doubled for twin pregnancies. No significant cost reduction for NICU care occurs beyond 35 weeks. A costeffective prematurity prevention program can include high-cost interventions, such as mandated referral for targeted specialized management of high risk groups such as twins.
261
RISK SCORING SYSTEM FOR PRETERM BIRTH: PROSPECTIVE ASSESSMENT AND ADDED VALUE OF PSYCHOSOCIAL AND DEMOGRAPHIC VARIABLES. MG Ross, M Sandhu x, R Bemis x , S NessirnX, JR Bragonier X , CJ Hobel. Dept. Ob/Gyn, Harbor-UCLA and Cedars Sinai Med. Ctrs., Torrance and Los Angeles, CA. OBJECTIVE: Few prematurity risk scoring systems have been rigorously tested prospectively. Using a retrospective data-base, we previously reported a simplified risk scoring (SRS) system for preterm birth among a predominantly Hispanic population. 1 We sought to: 1) validate the SRS in a prospective study, not Influenced by patients' risk status and 2) enhance the SRS system with additional psychosocial and demographic variables. At the first prenatal visit, patients in the STUDY DESIGN: control sites of the Los Angeles Prematurity Prevention Project received double blinded risk assessment and a psychosocial questionnaire. Delivery results and risk factor associations were assessed by mutt i-variate regression. RESULTS: Prospective analysis of the SRS resulted in a sensitivity of 43.8% and a specificity of 72.7% with 28% high risk patients, as compared to a predicted sensitivity of 55.6%, specificity of 68.4%, and 33% high risk. Three additional questionnaire variables were associated with preterm birth (race, ~2 preschool children, moving during pregnancy). When these factors were combined with the SRS score, and controlling for the observed sensitivity of 43.8%, the specificity significantly improved to 77.0% (p=0.001; 22% high risk). CONCLUSIONS: Risk scoring systems for prematurity may be significantly improved with the addition of psychosocial and demographic factors. 1 Ross et ai, Am J Perinatology, 1986; 3:339-344. Supported by CA Dept of Health Service, MCH Branch. Analyses and conclusions are those of the authors and not the State of CA.
262 PREIERM
LABOR: THE EFFECT OF RECENT SUBSTANCE USE ON THE OCCURRENCE OFPREIERM DELIVERY. JT Christmas, PH McGhee', MJ Dinsmoor, SJ Irons', KS Dawson', CW Kish'. Depts. OB/GYN & Biostatistics, VA Commonwealth University!Med. Col. VA, Richmond, VA OBJECTIVE: To evaluate the effect of recent substance use on (PTD) in patients with preterm labor (P1L). SIUDY DESIGN: Patients in P1L with toxicologic evidence of recent substance use (S+) were compared to those without (S-). The groups were analyzed with respect to risk factors for PTD including maternal age, race, gestational age and cervical dilatation at admission. P1L management was identical. RESULTS: Of 51 patients admitted in P1L, 23 (45%) had evidence of recent substance use. The most common substance detected was cocaine (16 of 23; 70%). There was no difference between the groups in maternal age, race, or gestational age at admission. S+ patients were more likely to have PTD within 48 hours of admission (19 of 23 vs 13 of 28; p<.02). This difference persisted after correction for differences in cervical dilatation at admission. CONCLUSION: Substance use increases the risk of PTD in patients presenting with P1L independent of dilatation at the time of admission. Supported by NIDA grant # DA 0609-04. All pts. Dil ~2cm Oil >2cm ~48 >48 ~48 >48 ~48 >48
:~ I: I': I ffiij
263
tHE
p=02
EPISIOTOMY DOES NOT PROTECT AGAINST INTRAVENTRICULAR HEMORRHAGE IN THE VERY LOW BIRTHWEIGHT.NEONATE. D Platel2', C Chazotte, x M Schulman Depts. Ob/Gyn & Peds, Albert Einstein Coli of Med, Bronx Municipal Hosp Ctr, Bronx, NY OBJECTIVE: To determine if routine episiotomy (EP) protects against the development of intraventricular hemorrhage (IVH) in the preterm infant. STUDY DESIGN: A review of delivery mode, presence of IVH, and early neonatal course of all infants weighing 501-1500 gms delivered between 1984-91 who had a head ultrasound within 72 hours of birth. Excluded were infants who were small for gestational age, anomalous, and those delivered vaginally with breech presentations. RESULTS: Of 205 who infants met the above criteria, there were no significant differences in the parity, birth wt, incidence or severity of IVH between the groups: No EP EP CS n=60 n=52 n=93 IVH present 16 (26.7%) 15 (28.8%) 23 (24.7%) Birth Wt (g) 1110.3 1125.4 1124.2 Wt <1000g 23 (38.3%) 18 (34.6%) 27 (29.0%) Confounding variables, degree of resuscitation, neonatal hypotension, development of pneumothorax, and neonatal thrombocytopenia within 72 hrs, were equally distributed among the 3 groups. CONCLUSION: This study suggests that prophylactic episiotomy does not decrease the incidence of early IVH in the very low birthweight infant.
371