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Maternal participation on preterm infants care reduces the cost of delivery of preterm neonatal healthcare services
Journal of Neonatal Nursing xxx (xxxx) xxx–xxx
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Maternal participation on preterm infants care reduces the cost of delivery of preterm neonatal healthcare services Nethong Namproma,∗, Patcharee Woragidpoonpolb, Leslie Altimierc, Usanee Jintrawetb, Jutamas Chotibangb, Pimpaporn Klunklinb a
Faculty of Nursing, Chiang Mai University, Chiang Mai, 50210, Thailand Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand c Northwestern Univesity, 35 Warren St., Newburyport, MA, United States b
ARTICLE INFO
ABSTRACT
Keywords: Preterm infants Growth Maternal participation Healthcare services cost Length of stay Innovation in healthcare
Background: Thailand, with an annual incidence rate of 12% ranks high in incidence of preterm birth. Preterm infants require specialized care which can be lengthy and costly both in terms of psychological and emotional stress and healthcare services. The rapid rise of cost of healthcare services is a major concern for Thai government and public. Purpose: To assess and compare the growth patterns and cost of delivery of healthcare services of 50 preterm infants who were randomly assigned to either the control arm or the Maternal Participation Program (MPP) arm of the study. Methods: 25 infants in the control arm and 25 infants in the MPP arm were followed up from the day of transfer to the neonatal ward until they were discharged from the hospital. Data on clinical parameters and cost of healthcare delivery were collected by reviewing medical charts and from institutional financial databases. The principle of intention-to-treat analysis was used to analyze the data using the SPSS package (Version 23). Results: The average hospital stay (53 days vs. 60, P = .427) and days of oxygen delivery (21 days vs. 45, P = .047) for infants in the MPP arm were shorter than the control. At discharge from hospital, growth velocity of infants in the control arm had caught up with the MPP arm. Overall costs of healthcare delivery services for the preterm infants in control arm were 1.75 times higher than those in the MPP arm, with the procedural services as the costliest. Costs of drugs and the other ancillary services for the control arm was about 3-fold higher than for the MPP arm. Conclusion: There were similar growth patterns and weight gain between the preterm infants in the control arm and the intervention arm. However, health care cost in preterm infants in the control arm was no statistically significant higher than those of the MPP arm. The difference of health care cost may arise from healthcare services and clinical interventions. Innovative and simple alternative strategy such as MPP can be an effective approach to curb the escalating cost of healthcare services.
1. Introduction The annual incidence of preterm births in the Asia-Pacific region varies from a low of 6% in Japan to a high of 16% in Pakistan. Thailand, with an annual incidence rate of 12% ranks high in incidence of preterm birth (OECD/World Health Organization, 2018). Preterm infants, because of their physiological immaturities require specialized care in neonatal intensive care units (NICU) which may cause lengthy separation of mothers from their infants (Kenner and Lott, 2014). The average length of stay (LoS) for a preterm infant in the NICU of Maharaj Nakorn Chiang Mai University Hospital, Thailand (MNCMUH) is about ∗
29 days (Pholanun, 2012). This relatively long period of separation can have negative psychological and emotional consequences on parents and their infants and increases cost of healthcare services (Stefana and Lavelli, 2017; Comert et al., 2012). This cost is negatively correlated with the gestation period, the shorter the gestation period, the higher the cost of healthcare services (Comert et al., 2012). The rapid rise of cost of healthcare services in Thailand has become a major concern for the Thai government and public. In Thailand, costs of delivery of healthcare services is shared between the government and consumers. Efforts have been underway to curb the cost, while maintaining, if not improving, the quality of healthcare services (World
Corresponding author. E-mail address: [email protected] (N. Namprom).
https://doi.org/10.1016/j.jnn.2020.03.005 Received 7 October 2019; Received in revised form 4 March 2020; Accepted 13 March 2020 1355-1841/ © 2020 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Nethong Namprom, et al., Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2020.03.005
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(Namprom et al., 2018). Components of the standard clinical care and the culturally MPP care are presented in Table 1. The MPP care included four sessions of 1-h on handling and caring for preterm infants which was followed by four 1-h sessions of hands-on training, under the direct supervision of one of the researchers. The other components of this culturally sensitive MPP intervention included creating healing environment, minimizing of infants' stress and pain, promoting and safeguarding of infants' sleep, protecting of infants' skins and optimization of infants’ nutrition (Table 1) (Namprom et al., 2018).
Health Organization, Regional Office for the Western Pacific, 2015, Sintavanarong, 2014; World Health Organization, Regional Office for the Western Pacific, 2015). Previously, we reported on the efficacy of a culturally sensitive Maternal Participation Program (MPP) that was implemented at the NICU of MNCMUH. (Namprom et al., 2018). This MPP was based on the Neonatal Integrative Development Model and incorporated the seven care model elements (partnering with family, creating a healing environment, optimizing nutrition, safeguarding sleep, positioning and handling, minimizing pain and stress, and protecting skin) (Altimier & Phillips, 2013, 2016). Preterm infants in the intervention arm of our study thrived, supported by statistically significant differences in the overall weight gain, growth velocity and neurobehavioral development scores at 14 and 28 days after birth (Namporm et al., 2018). However, the efficacy of MPP between 28 days of life (DoL), when most infants were transferred to the stepdown neonatal care unit, and day of hospital discharge is not known. Therefore, we implemented a follow-up study to assess the impact of MPP after infants were transferred from NICU to neonatal care unit. The objectives of this follow-up study were: 1) to assess and compare the growth pattern of infants in the intervention arm of the study with those in the control arm and 2) to compare the economic cost of healthcare services between the two groups at hospital discharge.
2.1. Data collection and outcomes measures One of the NICU nursing staff, trained by the researchers, collected body weight data on and data of the other clinical parameters by reviewing medical records of infants on daily basis. 2.2. Outcome measures Outcome measures were classified into three categories: 1) General characteristics; 2) Growth patterns of infants and 3) Cost of Delivery of Healthcare Service. Under the category of general characteristics, data were collected for the following variables: Length of NICU stay (in days); number of days on oxygen therapy (oxygen delivery days); number of days with exclusive breast feeding; and Illness symptoms. For the category of growth patterns, data on daily weight gain were collected, starting from the day of NICU admission until the day of discharge from hospital. We then calculated weight change at two different time points. The first weight change was calculated by subtracting weight at birth from weight measured on the day of discharge from NICU to the stepdown neonatal care unit; while, the second weight change was calculated by subtracting weight on the 28 DoL from weight at discharge from hospital. Weight gain velocity was calculated by measuring grams of body weight gain per day, and growth velocity was calculated by grams of weight gain per total body weight in kilograms per day. For the category of Delivery of Healthcare Service Cost, we obtained permission from the administration at MNCMUH to gain access to financial data. The research assistant through the assistance of the information technology staff at MNCMUH was able to download data that captured expensed incurred for the delivery of healthcare services. We divided costs of services into the total cost and expensed for each category of medications, laboratory tests, radiation therapy, procedural costs and daily “room and board” occupancy.
2. Methods The present follow-up study was spring-boarded from a previous Randomized Clinical Trial (RCT) study (Namprom et al., 2018). Briefly, 50 preterm neonates were randomly assigned to either the intervention arm (n = 25) of the study or to the control arm (n = 25) (Fig. 1.). The majority of the preterm infants in control group were male (male = 15 cases, female = 10 cases), a median gestational age of 31 weeks, with a mean birth weight of 1,353.60 g. The majority of the preterm infants in intervention group were male (male = 14 cases, female = 11 cases), a median gestational age of 31 weeks, with a mean birth weight of 1,439 g. At base line, there was no significant difference between the experimental and control groups in terms of infant sex, gestational age, birth weight (Namprom et al., 2018). The average gestational age at discharge for infants in the MPP group was 39.00 weeks (Range = 33–47) compared to 41.63 weeks (Range = 33–53) for the control group (p = .101). All infants received the standard clinical care. In addition, NICU nursing staff instructed mothers about hospital policies and procedures for visiting preterm infants, breast feeding, maternal and infant hygiene, care process of infants when ill, and growth support system. Furthermore, mothers were provided with information about the existing resources and support systems for daily care activities of preterm infants. The intervention group received culturally sensitive MPP care in addition to the standard cared. This culturally sensitive MPP was developed based on the Neonatal Integrative Developmental Care model of Altimier and Phillips (2013) with the objective of assisting mothers to effectively engage and participate in the care of their preterm infants
2.3. Statistics Intention-to-treat analysis was applied to account for the death of one infant at 37 weeks of gestation. Non-parametric statistics, i.e. Mann-Whitney U test and parametric statistics such as T-test were applied as appropriate, to conduct the statistical analysis. The statistician was masked to the source of data and conducted the analysis without knowing if the data were generated by the intervention or control
Fig. 1. Preterm infants in the control and intervention arms of the clinical trial study were followed up after 28 days in the NICU, when they were transferred to the neonatal ward until they were discharged from hospital. 2
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Table 1 Description of Components of Standard Clinical Care and the Culturally Sensitive MPP were Provided to Preterm Infants. Treatment Component
Standard Clinical Care
Culturally Sensitive Maternal Participation program
Unit guideline Breast Feeding Maternal & Infant hygiene Care of sick infant Teaching (4 1-hr. sessions) and Hands on Training (4 1-hr. sessions) included Creating healing environment - Provide intermittent kangaroo mother care (I-KMC) - Provide maternal scent using sterile swabs soaked with breast milk for their preterm infants to smell, and oral care with colostrum Positioning and Handing - Provide fetal position and facilitated tucking - Provide infant cues based care Minimizing Infant's Stress and Pain - Interpret infants' behavioral cues related to stress and pain, and provide comfort - Recognize their infants' stress cues and readiness cues for interaction at certain age. Promoting Safeguarding Infants' Sleep - Identifying infants' sleep state - Promote a quiet environment to uninterrupted infants' sleep - Delivery Intermittent Kangaroo Mother Care (I-KMC) to promote normal sleep patterns Protecting Infants' Skin - Delivering developmentally appropriate infant massages. - Provide skin care Optimizing Infants' Nutrition - Provide breast milk supply to preterm infants - Provide education on breast feeding
✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓
✓ ✓
Infants were stratified by sex and then ranked for their growth percentile. The proportion of male infants in the MPP group (44%, n = 11) in 97th growth percentile was higher than the control group (24%, n = 6) (P = .041). For female infants this difference did not reach the level of statistical significance (P = .126) (Table 4). By the time of discharge from hospital, growth velocity of infants in the control group had caught up with the MPP group (Fig. 2). Healthcare Delivery Service Costs: Mean values, absolute and relative differences of costs of various healthcare services for the control and the intervention groups are listed in Table 5. Overall, the total costs of healthcare delivery services for the preterm infants in control group were 1.75 times higher than those in the MPP group, with the absolute difference of 195,568.2 Thai Baht (Table 5). Among the different types of healthcare services, the procedural services were the costliest. The total procedural costs for the control group (229,894 Thai Baht) was almost two-fold higher than for the MPP group (118,946.8 Thai Baht), with the absolute difference of 110,947.2 Thai Baht. Costs of drugs and the other ancillary services for the control group was about 3-fold higher (12,678.4 Thai Baht) than for the MPP group (3,847.40 Thai Baht).
group. 2.4. Research ethics and institutional approval This research was approved by the Research Ethics Committee, Faculty of Nursing and Faculty of Medicine, Chiang Mai University (NONE-2560-05175). Research personnel received the required training and certification to conduct clinical-based research. 3. Results General Characteristics. The average gestational age at discharge for infants in the MPP group was 39.00 weeks (Range = 34–47) compared to 41.63 weeks (Range = 33–53) for the control group (p = .101). Although, the average total length of NICU stay of the preterm infants in MPP group was shorter (53 days, range = 12–130) than those in the control group (60 days, range = 15–173), the difference in length of stay did not reach the level of statistical significance (p = .427). The average days of oxygen delivery for the preterm infants in MPP group (21.5 days, Range = 1–74) which was statistically significantly shorter than those in the control group (44.7 days, Range = 1–173) (p = .047) (Table 2). Preterm infants in the MPP group had fewer signs and symptoms of adverse health conditions compared to the control group. One infant in the control group died from bronchopulmonary dysplasia on day 77. The proportion of infants who were exclusively breastfed was higher in the MPP group (80%, n = 20) than in the control group (52%, n = 13); although, this difference did not reach the level of statistical significance (p = .831). Growth Patterns. All preterm infants were stratified by sex and body weight according to the Fenton growth chart criteria (Fenton and Kim, 2013). At 28 days of life, the mean weight gain velocity for the infants in the MPP group was 29.21 g per day (Range = 16.72–53.25) and 24.23 g per day (Range = 10.43–51.25) in the control group. This difference approached the level of statistical significance (P = .061) (Table 3). Similarly, the mean rate of growth velocity of the infants in the MPP group (14.08 g/kg/day, Range = 15.93–33.82) was comparable to those in the control group (12.60 g/kg/day, Range = 24.25–5.41) (P = .233) (Table 3).
4. Discussion This study was conducted to assess the impact of a culturally sensitive MPP on growth and development of preterm infants and the associated cost of delivery of healthcare services. At the initiation of intervention, infants whose mothers participated in the culturally sensitive MPP arm of the study, had higher growth rates and weight gain velocities; however, infants in the control group eventually were able to catch-up with weigh gain and overall growth (Namprom et al., 2018). Mean growth velocity of preterm infants is generally 14 g/kg/ day in the first 5 weeks after birth (Steward, 2012). The growth velocity of the two groups after 28 days of age met this criterion. Most likely the quality of healthcare services along with the intensity and frequency contacts of healthcare providers with the infants in the control group attributed to their catching up in weight gain and overall growth. The overall cost of delivery of healthcare services was higher for infants in the control group, which is an indirect indication for more interventions 3
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Table 2 Demographic and treatment data of mothers and preterm infants in Intervention group (Maternal Participation Program) and Control group (standard clinical care).
Preterm infants Days on TPN, mean (SD) Days of full feeding, mean (SD) Breastmilk from birth to discharge Illness from DoL 28 to discharge 1) Respiratory system BPD AOP Pulmonary hypertension Pneumonia 2) Gastrointestinal system Feeding intolerance Small bowel obstruction 3) Hematology Sepsis Anemia 4) Neurological system IVH ROP 5) Musculoskeletal Osteopenia 6) Renal system Renal insufficiency Oxygen therapy (days), mean (SD) ETT with ventilator NIPPV NPCAP Bubble CPAP Cannula high flow Cannula low flow Length of Hospital stay (days), mean (SD) GA at birth (SD) PCA at hospital discharge (SD) Weight at hospital discharge (SD) Healthcare Insurance Universal health coverage scheme
MPP group (N = 25)
Control group (N = 25)
N
n
%
7.88 (4.14) 10.16 (5.54) 20 80
Table 3 Indicators of weight gain and growth patterns of infants in the intervention group and the control group. Variables
P -value
%
9.80 (5.45) 12.29 (5.89) 13 52
32 40 – –
9 7 1 1
36 28 4 4
2 –
1 1
4 4
– 8
8 – – – 32
1 3
4 12
2 3
8 12
8 7
32 28
–
–
1
4
.198 .198 .831
Variable
1 4 44.73 (51.77)
4.31 (7.36) 2.04 (5.17) 4.255.94 2.08 (5.13) 7.20 (8.55) 2.08 (5.16) 53 (25.0)
18.74 (36.18) 0.85 (2.64) 4.356.62 0.60 (3.00) 18.97 (29.56) 1.2 (4.5) 60 (32)
30.92 (1.52) 38.98 (2.26) 2897.76 (536.62)
30.76 (1.42) 41.63 (5.33) 2807.60 (635.16)
.753 .101
22
21
.670
84
Mean ± SD
Mean ± SD
P -value
760.04 9.24
1,482 ± 821.33 24.13 ± 9.47
.784 .061
3.99
12.60 ± 4.64
.233
± 869.01 8.79
1,388.68 ± 811.99 31.89 ± 18.24
.328 .695
3.55
14.47 ± 6.56
.876
Table 4 Distribution of infants by sex and growth percentile based on Fenton growth chart category at discharge date.
– – 21.47 (21.46)
88
Control group N = 25
Growth Compared from birthweight Weight gain (g) 1,420 ± Weight gain velocity 29.21 ± (g/d) Growth velocity 14.08 ± (g/kg/d) Compared from 28 days of life Weight gain (g) 1,118.10 Weight gain velocity 33.03 ± (g/d) Growth velocity 14.21 ± (g/kg/d)
.182 8 10 – –
MPP group N = 25
Male Female
.047
Experimental group (n = 25)
Control group (n = 25)
< 3rd percentile
3rd – 97th percentile
< 3rd percentile
3rd – 97th percentile
3 1
11 10
9 4
6 6
P-value
0.041 0.126
and the Thai government. Innovation in the delivery of healthcare services is one effective way to curb the cost of healthcare in Thailand. Findings from our study support that a culturally sensitive MPP reduces the cost of delivery of healthcare services. In our study, preterm infants in the MPP arm of our study had lower overall hospitalization costs, even though, on the average they had shorter gestational period by two weeks. The mean gestational period for preterm infants was 41 weeks and 39 weeks for the preterm infants in the culturally sensitive MPP arm of the study. This observation is particularly important because it is well accepted that cost of delivery of healthcare services is inversely correlated with the gestational period (Comert et al., 2012). We attribute this lower cost to shorter duration of oxygen therapy and having fewer signs and symptoms of diseases among the preterm infants in the culturally sensitive arm of our study. Indeed, cost of the procedural healthcare services for infants in the MPP arm of our study was almost half of the cost for the control arm. Our findings concur with a previous study conducted in Turkey that interventional procedures are the main reason for the high cost of delivery healthcare services for preterm infants. The annual costs for all preterm infants in Turkey was $883,535 (Comert et al., 2012). This data supports the fact that the MPP can reduce cost of healthcare services in neonatal intensive care units, mothers should play an essential role in participating in their infant's NICU care.
.427
∗ = One infant had illness with more than one symptom and had been fed by more than one method; data presented as number (percentage) unless indicated otherwise; TPN = Total parenteral nutrition; DoI = Day of life; PCA = Postconceptional Age; BPD = Bronchopulmonary Dysplasia; NEC = Necrotizing Enterocolitis; IVH = Intraventricular Hemorrhage; ROP = Retinopathy of Prematurity; HAI = Hospital Acquired Infection.
and higher frequency of delivery of healthcare services. Our findings of no difference in weight gain and growth velocity between the two groups of infants concur with previous reports. (Beheshtipoor et al., 2013). However, the infants in the experimental group, especially male infants, were at a more optimum growth range, on the Fenton growth chart, than the control group (Fenton and Kim, 2013). The findings also demonstrated that infants whose mothers were involved in the MPP had less complications, and less illnesses developed after 28 days of age than those in the control group. Findings in this study were also consistent with a previous study in terms of shortened hospital length of stay (Beheshtipoor et al., 2013; Peters et al., 2009) and a reduced incidence of chronic lung disease and intraventricular hemorrhage (Altimier et a., 2004; Melnyk et al., 2006). The escalating cost of healthcare services is a concern to both of the Thai government and public who share responsibility of these costs. The cost of healthcare services is a shared responsibility between consumers
4.1. Limitations Our study has several limitations. First, the sample size in this study was obtained by the calculation, power analysis. However, the results do not show any significant of the variables. Further study is required with more sample size. Second, mothers in this study were northern Thai group who have their own culture of postpartum and newborn care, thus the result of this study may not be generalization. Third, in this study, the data of health care costs were calculated from the secondary source of the hospital record as overall expenditure. So, the researcher had to classify health care costs based on the literature 4
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Fig. 2. Comparison of weight gain velocity between infants in the MPP and the control group.
psychological well-being mother and their children also should be evaluated. Thai government and governments across the globe are striving to find constructive solutions to the rapid increase in the cost of healthcare services. Innovative and simple alternative strategy such as MPP can be an effective approach to curb the escalating cost of healthcare services.
Table 5 Costs of healthcare services delivered to preterm infants in the intervention group and the control group. Healthcare Service Type
Costs in Thai Bahta Control Group Mean value
MPP Group Mean value
Absolute difference
Relative difference
Radiation Therapy Drugs and Ancillary Laboratory Costs Other servicesb Procedural Costs Total Costs
7,172.4
3,741.2
3,431.2
1.92
12,678.4
3,847.4
8,831.0
3.29
27,814.20 171,616.0 229,894.0 454,967.0
13,317.2 118,868.0 118,946.8 259,398.8
14,497.0 52,748.0 110,947.2 195,568.2
2.09 1.44 1.93 1.75
a b
Ethical statement This research has been certified by the Research Ethics Committee, Faculty of Nursing and Faculty of Medicine, Chiang Mai University (NONE-2560-05175). Research personnel received the required training and certification to conduct clinical-based research. Declaration of competing interest
One US Dollar equal to 30 Thai Baht. Other required healthcare services, i.e. hospital room services.
The authors declare no conflict of interest in this study.
review. Thus, health care settings should take into consideration in the classification of health care cost. By doing this, it may shed the light on the real cost of health care services, and it may count as innovative approach in the delivery of healthcare services.
Acknowledgment This research project was funded by a grant from the Research Fund, Faculty of Nursing, International University of Chiang Mai, Thailand. The authors thank Dr. Azadeh Stark, University of Texas at Dallas for her helpful technical suggestions.
5. Conclusion
References
The overall growth patterns and weight gain of the preterm infants in the control arm of study and the intervention arm of were similar; however, costs of healthcare services were substantially higher in infants of the control group compared to the intervention group, indicating a higher volume of healthcare services and clinical interventions. Findings from our study suggest that maternal participation in the delivery of preterm infants healthcare services, is an effective approach in reducing the cost of healthcare while maintaining the quality. Larger and longer duration randomized clinical trials are needed for further confirmation of findings. Other outcomes such as bonding, long-term
Altimier, L., Phillips, R.M., 2013. The Neonatal integrative developmental care model: seven neuroprotective core measures for family-centered developmental care. N.born Infant Nurs. Rev. 13 (1), 9–22. Altimier, L., Phillips, R.M., 2016. The Neonatal Integrative Development Care Model: advanced clinical applications of the seven core measures for neuroprotective familycentered developmental care. N.born Infant Nurs. Rev. 16, 230–244. Altimier, L., Warner, B., Eichel, M., Warn, B., Tedeschi, L., Brown, B., 2004. Developmental care: changing the NICU physically and behaviorally to promote patient outcomes and contain costs. Neonatal Intensive Care 17 (2), 35–39. Beheshtipoor, N., Shaker, Z., Edraki, M., Razavi, R., Zare, Z., 2013. The effect of family-
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N. Namprom, et al. based empowerment program on the weight and length of hospital stay of preterm infants in the neonatal intensive care unit. Galen Med. J 2 (3), 114–119. Comert, S., Agzikuru, T., Akin, Y., Telatar, B., Tan, P.D., Ergen, S.G., et al., 2012. The cost analysis of preterm infants from a NICU of a State Hospital in Istanbul. Iran. J. Pediatr. (Engl. Ed.) 22 (2), 185–190. Fenton, T.R., Kim, J.H., 2013. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BioMed Cent. Pediatr. 13, 59. Kenner, C., Loot, J.W., 2014. Comprehensive Neonatal Nursing Care, fifth ed. Springer, New York. Melnyk, B.M., Feinstein, N.F., Alpert-Gillis, L., Fairbanks, E., Crean, H.F., Sinkin, R.A., et al., 2006. Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics 118, e1414–e1427. Namprom, N., Picheansathian, W., Jintrawet, U., Chotibang, J., 2018. The effect of maternal participation in preterm's care and improved short-term growth and neurodevelopment outcomes. J. Neonatal Nurs. 24 (4), 196–202. https://doi.org/10.1016/ j.jnn.2018.03.003. OECD/World Health Organization, 2018. Preterm Birth and Low Birth Weight” in Health at a Glance: Asia/Pacific 2018: Measuring Progress towards Universal Health Coverage. OECD Publishing, Paris. https://doi.org/10.1787/health_glance_ap-201821-en. Retrieve form. Peters, K.L., Rosychuk, R.J., Hendson, L., Cote, J.J., McPherson, C., Tyebkhan, J.M., 2009. Improvement of short- and long-term outcomes for very low birth weight infants: edmonton NIDCAP trial. Pediatrics 124 (4), 1009–1020. Pholanun, P., 2012. Maternal Participation in Caring for Preterm Infants in Neonatal Intensive Care Unit and Related Factors (master’s thesis). Chiang Mai: Graduate schoo,l Chiang Mai University, pp. 131 (in Thai). Sintavanarong, P., 2014. Healthcare system in Thailand: past-present and where is the
future ? Minister of Ministry of Public Health, Thailand. Stefana, A., Lavelli, M., 2017. Parental engagement and early interactions with preterm infants during the stay in the neonatal intensive care unit: protocol of a mixedmethod and longitudinal study. Br. Med. J. Open. 7, e013824. https://doi.org/10. 1136/bmjopen-2016-013824. Steward, D.K., 2012. Growth outcomes of preterm infants in the neonatal intensive care unit long-term considerations. N.born Infant Nurs. Rev. 12 (4), 214–220. World Health Organization, Regional Office for the Western Pacific, 2015. The Kingdom of Thailand Health System Review. Manila : WHO Regional Office for the Western Pacific Retrieve form. https://apps.who.int/iris/handle/10665/208216.
Glossary BPD: Bronchopulmonary Dysplasia DoL: Day of Life HAI: Hospital Acquired Infection IVH: Intraventricular Hemorrhage LoS: Length of Stay MPP: Maternal Participation Program NEC: Necrotizing Enterocolitis NICU: Neonatal Intensive Care Unit PCA: Post-conceptional Age ROP: Retinopathy of Prematurity TPN: Total Parenteral Nutrition g/day: gram per day g/kg/day: gram per kilogram per day $: US dollar
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Contents lists available at ScienceDirect
Journal of Neonatal Nursing journal homepage: www.elsevier.com/locate/jnn
Maternal participation on preterm infants care reduces the cost of delivery of preterm neonatal healthcare services Nethong Namproma,∗, Patcharee Woragidpoonpolb, Leslie Altimierc, Usanee Jintrawetb, Jutamas Chotibangb, Pimpaporn Klunklinb a
Faculty of Nursing, Chiang Mai University, Chiang Mai, 50210, Thailand Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand c Northwestern Univesity, 35 Warren St., Newburyport, MA, United States b
ARTICLE INFO
ABSTRACT
Keywords: Preterm infants Growth Maternal participation Healthcare services cost Length of stay Innovation in healthcare
Background: Thailand, with an annual incidence rate of 12% ranks high in incidence of preterm birth. Preterm infants require specialized care which can be lengthy and costly both in terms of psychological and emotional stress and healthcare services. The rapid rise of cost of healthcare services is a major concern for Thai government and public. Purpose: To assess and compare the growth patterns and cost of delivery of healthcare services of 50 preterm infants who were randomly assigned to either the control arm or the Maternal Participation Program (MPP) arm of the study. Methods: 25 infants in the control arm and 25 infants in the MPP arm were followed up from the day of transfer to the neonatal ward until they were discharged from the hospital. Data on clinical parameters and cost of healthcare delivery were collected by reviewing medical charts and from institutional financial databases. The principle of intention-to-treat analysis was used to analyze the data using the SPSS package (Version 23). Results: The average hospital stay (53 days vs. 60, P = .427) and days of oxygen delivery (21 days vs. 45, P = .047) for infants in the MPP arm were shorter than the control. At discharge from hospital, growth velocity of infants in the control arm had caught up with the MPP arm. Overall costs of healthcare delivery services for the preterm infants in control arm were 1.75 times higher than those in the MPP arm, with the procedural services as the costliest. Costs of drugs and the other ancillary services for the control arm was about 3-fold higher than for the MPP arm. Conclusion: There were similar growth patterns and weight gain between the preterm infants in the control arm and the intervention arm. However, health care cost in preterm infants in the control arm was no statistically significant higher than those of the MPP arm. The difference of health care cost may arise from healthcare services and clinical interventions. Innovative and simple alternative strategy such as MPP can be an effective approach to curb the escalating cost of healthcare services.
1. Introduction The annual incidence of preterm births in the Asia-Pacific region varies from a low of 6% in Japan to a high of 16% in Pakistan. Thailand, with an annual incidence rate of 12% ranks high in incidence of preterm birth (OECD/World Health Organization, 2018). Preterm infants, because of their physiological immaturities require specialized care in neonatal intensive care units (NICU) which may cause lengthy separation of mothers from their infants (Kenner and Lott, 2014). The average length of stay (LoS) for a preterm infant in the NICU of Maharaj Nakorn Chiang Mai University Hospital, Thailand (MNCMUH) is about ∗
29 days (Pholanun, 2012). This relatively long period of separation can have negative psychological and emotional consequences on parents and their infants and increases cost of healthcare services (Stefana and Lavelli, 2017; Comert et al., 2012). This cost is negatively correlated with the gestation period, the shorter the gestation period, the higher the cost of healthcare services (Comert et al., 2012). The rapid rise of cost of healthcare services in Thailand has become a major concern for the Thai government and public. In Thailand, costs of delivery of healthcare services is shared between the government and consumers. Efforts have been underway to curb the cost, while maintaining, if not improving, the quality of healthcare services (World
Corresponding author. E-mail address: [email protected] (N. Namprom).
https://doi.org/10.1016/j.jnn.2020.03.005 Received 7 October 2019; Received in revised form 4 March 2020; Accepted 13 March 2020 1355-1841/ © 2020 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.
Please cite this article as: Nethong Namprom, et al., Journal of Neonatal Nursing, https://doi.org/10.1016/j.jnn.2020.03.005
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(Namprom et al., 2018). Components of the standard clinical care and the culturally MPP care are presented in Table 1. The MPP care included four sessions of 1-h on handling and caring for preterm infants which was followed by four 1-h sessions of hands-on training, under the direct supervision of one of the researchers. The other components of this culturally sensitive MPP intervention included creating healing environment, minimizing of infants' stress and pain, promoting and safeguarding of infants' sleep, protecting of infants' skins and optimization of infants’ nutrition (Table 1) (Namprom et al., 2018).
Health Organization, Regional Office for the Western Pacific, 2015, Sintavanarong, 2014; World Health Organization, Regional Office for the Western Pacific, 2015). Previously, we reported on the efficacy of a culturally sensitive Maternal Participation Program (MPP) that was implemented at the NICU of MNCMUH. (Namprom et al., 2018). This MPP was based on the Neonatal Integrative Development Model and incorporated the seven care model elements (partnering with family, creating a healing environment, optimizing nutrition, safeguarding sleep, positioning and handling, minimizing pain and stress, and protecting skin) (Altimier & Phillips, 2013, 2016). Preterm infants in the intervention arm of our study thrived, supported by statistically significant differences in the overall weight gain, growth velocity and neurobehavioral development scores at 14 and 28 days after birth (Namporm et al., 2018). However, the efficacy of MPP between 28 days of life (DoL), when most infants were transferred to the stepdown neonatal care unit, and day of hospital discharge is not known. Therefore, we implemented a follow-up study to assess the impact of MPP after infants were transferred from NICU to neonatal care unit. The objectives of this follow-up study were: 1) to assess and compare the growth pattern of infants in the intervention arm of the study with those in the control arm and 2) to compare the economic cost of healthcare services between the two groups at hospital discharge.
2.1. Data collection and outcomes measures One of the NICU nursing staff, trained by the researchers, collected body weight data on and data of the other clinical parameters by reviewing medical records of infants on daily basis. 2.2. Outcome measures Outcome measures were classified into three categories: 1) General characteristics; 2) Growth patterns of infants and 3) Cost of Delivery of Healthcare Service. Under the category of general characteristics, data were collected for the following variables: Length of NICU stay (in days); number of days on oxygen therapy (oxygen delivery days); number of days with exclusive breast feeding; and Illness symptoms. For the category of growth patterns, data on daily weight gain were collected, starting from the day of NICU admission until the day of discharge from hospital. We then calculated weight change at two different time points. The first weight change was calculated by subtracting weight at birth from weight measured on the day of discharge from NICU to the stepdown neonatal care unit; while, the second weight change was calculated by subtracting weight on the 28 DoL from weight at discharge from hospital. Weight gain velocity was calculated by measuring grams of body weight gain per day, and growth velocity was calculated by grams of weight gain per total body weight in kilograms per day. For the category of Delivery of Healthcare Service Cost, we obtained permission from the administration at MNCMUH to gain access to financial data. The research assistant through the assistance of the information technology staff at MNCMUH was able to download data that captured expensed incurred for the delivery of healthcare services. We divided costs of services into the total cost and expensed for each category of medications, laboratory tests, radiation therapy, procedural costs and daily “room and board” occupancy.
2. Methods The present follow-up study was spring-boarded from a previous Randomized Clinical Trial (RCT) study (Namprom et al., 2018). Briefly, 50 preterm neonates were randomly assigned to either the intervention arm (n = 25) of the study or to the control arm (n = 25) (Fig. 1.). The majority of the preterm infants in control group were male (male = 15 cases, female = 10 cases), a median gestational age of 31 weeks, with a mean birth weight of 1,353.60 g. The majority of the preterm infants in intervention group were male (male = 14 cases, female = 11 cases), a median gestational age of 31 weeks, with a mean birth weight of 1,439 g. At base line, there was no significant difference between the experimental and control groups in terms of infant sex, gestational age, birth weight (Namprom et al., 2018). The average gestational age at discharge for infants in the MPP group was 39.00 weeks (Range = 33–47) compared to 41.63 weeks (Range = 33–53) for the control group (p = .101). All infants received the standard clinical care. In addition, NICU nursing staff instructed mothers about hospital policies and procedures for visiting preterm infants, breast feeding, maternal and infant hygiene, care process of infants when ill, and growth support system. Furthermore, mothers were provided with information about the existing resources and support systems for daily care activities of preterm infants. The intervention group received culturally sensitive MPP care in addition to the standard cared. This culturally sensitive MPP was developed based on the Neonatal Integrative Developmental Care model of Altimier and Phillips (2013) with the objective of assisting mothers to effectively engage and participate in the care of their preterm infants
2.3. Statistics Intention-to-treat analysis was applied to account for the death of one infant at 37 weeks of gestation. Non-parametric statistics, i.e. Mann-Whitney U test and parametric statistics such as T-test were applied as appropriate, to conduct the statistical analysis. The statistician was masked to the source of data and conducted the analysis without knowing if the data were generated by the intervention or control
Fig. 1. Preterm infants in the control and intervention arms of the clinical trial study were followed up after 28 days in the NICU, when they were transferred to the neonatal ward until they were discharged from hospital. 2
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Table 1 Description of Components of Standard Clinical Care and the Culturally Sensitive MPP were Provided to Preterm Infants. Treatment Component
Standard Clinical Care
Culturally Sensitive Maternal Participation program
Unit guideline Breast Feeding Maternal & Infant hygiene Care of sick infant Teaching (4 1-hr. sessions) and Hands on Training (4 1-hr. sessions) included Creating healing environment - Provide intermittent kangaroo mother care (I-KMC) - Provide maternal scent using sterile swabs soaked with breast milk for their preterm infants to smell, and oral care with colostrum Positioning and Handing - Provide fetal position and facilitated tucking - Provide infant cues based care Minimizing Infant's Stress and Pain - Interpret infants' behavioral cues related to stress and pain, and provide comfort - Recognize their infants' stress cues and readiness cues for interaction at certain age. Promoting Safeguarding Infants' Sleep - Identifying infants' sleep state - Promote a quiet environment to uninterrupted infants' sleep - Delivery Intermittent Kangaroo Mother Care (I-KMC) to promote normal sleep patterns Protecting Infants' Skin - Delivering developmentally appropriate infant massages. - Provide skin care Optimizing Infants' Nutrition - Provide breast milk supply to preterm infants - Provide education on breast feeding
✓ ✓ ✓ ✓
✓ ✓ ✓ ✓ ✓ ✓
✓ ✓ ✓
✓ ✓
Infants were stratified by sex and then ranked for their growth percentile. The proportion of male infants in the MPP group (44%, n = 11) in 97th growth percentile was higher than the control group (24%, n = 6) (P = .041). For female infants this difference did not reach the level of statistical significance (P = .126) (Table 4). By the time of discharge from hospital, growth velocity of infants in the control group had caught up with the MPP group (Fig. 2). Healthcare Delivery Service Costs: Mean values, absolute and relative differences of costs of various healthcare services for the control and the intervention groups are listed in Table 5. Overall, the total costs of healthcare delivery services for the preterm infants in control group were 1.75 times higher than those in the MPP group, with the absolute difference of 195,568.2 Thai Baht (Table 5). Among the different types of healthcare services, the procedural services were the costliest. The total procedural costs for the control group (229,894 Thai Baht) was almost two-fold higher than for the MPP group (118,946.8 Thai Baht), with the absolute difference of 110,947.2 Thai Baht. Costs of drugs and the other ancillary services for the control group was about 3-fold higher (12,678.4 Thai Baht) than for the MPP group (3,847.40 Thai Baht).
group. 2.4. Research ethics and institutional approval This research was approved by the Research Ethics Committee, Faculty of Nursing and Faculty of Medicine, Chiang Mai University (NONE-2560-05175). Research personnel received the required training and certification to conduct clinical-based research. 3. Results General Characteristics. The average gestational age at discharge for infants in the MPP group was 39.00 weeks (Range = 34–47) compared to 41.63 weeks (Range = 33–53) for the control group (p = .101). Although, the average total length of NICU stay of the preterm infants in MPP group was shorter (53 days, range = 12–130) than those in the control group (60 days, range = 15–173), the difference in length of stay did not reach the level of statistical significance (p = .427). The average days of oxygen delivery for the preterm infants in MPP group (21.5 days, Range = 1–74) which was statistically significantly shorter than those in the control group (44.7 days, Range = 1–173) (p = .047) (Table 2). Preterm infants in the MPP group had fewer signs and symptoms of adverse health conditions compared to the control group. One infant in the control group died from bronchopulmonary dysplasia on day 77. The proportion of infants who were exclusively breastfed was higher in the MPP group (80%, n = 20) than in the control group (52%, n = 13); although, this difference did not reach the level of statistical significance (p = .831). Growth Patterns. All preterm infants were stratified by sex and body weight according to the Fenton growth chart criteria (Fenton and Kim, 2013). At 28 days of life, the mean weight gain velocity for the infants in the MPP group was 29.21 g per day (Range = 16.72–53.25) and 24.23 g per day (Range = 10.43–51.25) in the control group. This difference approached the level of statistical significance (P = .061) (Table 3). Similarly, the mean rate of growth velocity of the infants in the MPP group (14.08 g/kg/day, Range = 15.93–33.82) was comparable to those in the control group (12.60 g/kg/day, Range = 24.25–5.41) (P = .233) (Table 3).
4. Discussion This study was conducted to assess the impact of a culturally sensitive MPP on growth and development of preterm infants and the associated cost of delivery of healthcare services. At the initiation of intervention, infants whose mothers participated in the culturally sensitive MPP arm of the study, had higher growth rates and weight gain velocities; however, infants in the control group eventually were able to catch-up with weigh gain and overall growth (Namprom et al., 2018). Mean growth velocity of preterm infants is generally 14 g/kg/ day in the first 5 weeks after birth (Steward, 2012). The growth velocity of the two groups after 28 days of age met this criterion. Most likely the quality of healthcare services along with the intensity and frequency contacts of healthcare providers with the infants in the control group attributed to their catching up in weight gain and overall growth. The overall cost of delivery of healthcare services was higher for infants in the control group, which is an indirect indication for more interventions 3
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Table 2 Demographic and treatment data of mothers and preterm infants in Intervention group (Maternal Participation Program) and Control group (standard clinical care).
Preterm infants Days on TPN, mean (SD) Days of full feeding, mean (SD) Breastmilk from birth to discharge Illness from DoL 28 to discharge 1) Respiratory system BPD AOP Pulmonary hypertension Pneumonia 2) Gastrointestinal system Feeding intolerance Small bowel obstruction 3) Hematology Sepsis Anemia 4) Neurological system IVH ROP 5) Musculoskeletal Osteopenia 6) Renal system Renal insufficiency Oxygen therapy (days), mean (SD) ETT with ventilator NIPPV NPCAP Bubble CPAP Cannula high flow Cannula low flow Length of Hospital stay (days), mean (SD) GA at birth (SD) PCA at hospital discharge (SD) Weight at hospital discharge (SD) Healthcare Insurance Universal health coverage scheme
MPP group (N = 25)
Control group (N = 25)
N
n
%
7.88 (4.14) 10.16 (5.54) 20 80
Table 3 Indicators of weight gain and growth patterns of infants in the intervention group and the control group. Variables
P -value
%
9.80 (5.45) 12.29 (5.89) 13 52
32 40 – –
9 7 1 1
36 28 4 4
2 –
1 1
4 4
– 8
8 – – – 32
1 3
4 12
2 3
8 12
8 7
32 28
–
–
1
4
.198 .198 .831
Variable
1 4 44.73 (51.77)
4.31 (7.36) 2.04 (5.17) 4.255.94 2.08 (5.13) 7.20 (8.55) 2.08 (5.16) 53 (25.0)
18.74 (36.18) 0.85 (2.64) 4.356.62 0.60 (3.00) 18.97 (29.56) 1.2 (4.5) 60 (32)
30.92 (1.52) 38.98 (2.26) 2897.76 (536.62)
30.76 (1.42) 41.63 (5.33) 2807.60 (635.16)
.753 .101
22
21
.670
84
Mean ± SD
Mean ± SD
P -value
760.04 9.24
1,482 ± 821.33 24.13 ± 9.47
.784 .061
3.99
12.60 ± 4.64
.233
± 869.01 8.79
1,388.68 ± 811.99 31.89 ± 18.24
.328 .695
3.55
14.47 ± 6.56
.876
Table 4 Distribution of infants by sex and growth percentile based on Fenton growth chart category at discharge date.
– – 21.47 (21.46)
88
Control group N = 25
Growth Compared from birthweight Weight gain (g) 1,420 ± Weight gain velocity 29.21 ± (g/d) Growth velocity 14.08 ± (g/kg/d) Compared from 28 days of life Weight gain (g) 1,118.10 Weight gain velocity 33.03 ± (g/d) Growth velocity 14.21 ± (g/kg/d)
.182 8 10 – –
MPP group N = 25
Male Female
.047
Experimental group (n = 25)
Control group (n = 25)
< 3rd percentile
3rd – 97th percentile
< 3rd percentile
3rd – 97th percentile
3 1
11 10
9 4
6 6
P-value
0.041 0.126
and the Thai government. Innovation in the delivery of healthcare services is one effective way to curb the cost of healthcare in Thailand. Findings from our study support that a culturally sensitive MPP reduces the cost of delivery of healthcare services. In our study, preterm infants in the MPP arm of our study had lower overall hospitalization costs, even though, on the average they had shorter gestational period by two weeks. The mean gestational period for preterm infants was 41 weeks and 39 weeks for the preterm infants in the culturally sensitive MPP arm of the study. This observation is particularly important because it is well accepted that cost of delivery of healthcare services is inversely correlated with the gestational period (Comert et al., 2012). We attribute this lower cost to shorter duration of oxygen therapy and having fewer signs and symptoms of diseases among the preterm infants in the culturally sensitive arm of our study. Indeed, cost of the procedural healthcare services for infants in the MPP arm of our study was almost half of the cost for the control arm. Our findings concur with a previous study conducted in Turkey that interventional procedures are the main reason for the high cost of delivery healthcare services for preterm infants. The annual costs for all preterm infants in Turkey was $883,535 (Comert et al., 2012). This data supports the fact that the MPP can reduce cost of healthcare services in neonatal intensive care units, mothers should play an essential role in participating in their infant's NICU care.
.427
∗ = One infant had illness with more than one symptom and had been fed by more than one method; data presented as number (percentage) unless indicated otherwise; TPN = Total parenteral nutrition; DoI = Day of life; PCA = Postconceptional Age; BPD = Bronchopulmonary Dysplasia; NEC = Necrotizing Enterocolitis; IVH = Intraventricular Hemorrhage; ROP = Retinopathy of Prematurity; HAI = Hospital Acquired Infection.
and higher frequency of delivery of healthcare services. Our findings of no difference in weight gain and growth velocity between the two groups of infants concur with previous reports. (Beheshtipoor et al., 2013). However, the infants in the experimental group, especially male infants, were at a more optimum growth range, on the Fenton growth chart, than the control group (Fenton and Kim, 2013). The findings also demonstrated that infants whose mothers were involved in the MPP had less complications, and less illnesses developed after 28 days of age than those in the control group. Findings in this study were also consistent with a previous study in terms of shortened hospital length of stay (Beheshtipoor et al., 2013; Peters et al., 2009) and a reduced incidence of chronic lung disease and intraventricular hemorrhage (Altimier et a., 2004; Melnyk et al., 2006). The escalating cost of healthcare services is a concern to both of the Thai government and public who share responsibility of these costs. The cost of healthcare services is a shared responsibility between consumers
4.1. Limitations Our study has several limitations. First, the sample size in this study was obtained by the calculation, power analysis. However, the results do not show any significant of the variables. Further study is required with more sample size. Second, mothers in this study were northern Thai group who have their own culture of postpartum and newborn care, thus the result of this study may not be generalization. Third, in this study, the data of health care costs were calculated from the secondary source of the hospital record as overall expenditure. So, the researcher had to classify health care costs based on the literature 4
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Fig. 2. Comparison of weight gain velocity between infants in the MPP and the control group.
psychological well-being mother and their children also should be evaluated. Thai government and governments across the globe are striving to find constructive solutions to the rapid increase in the cost of healthcare services. Innovative and simple alternative strategy such as MPP can be an effective approach to curb the escalating cost of healthcare services.
Table 5 Costs of healthcare services delivered to preterm infants in the intervention group and the control group. Healthcare Service Type
Costs in Thai Bahta Control Group Mean value
MPP Group Mean value
Absolute difference
Relative difference
Radiation Therapy Drugs and Ancillary Laboratory Costs Other servicesb Procedural Costs Total Costs
7,172.4
3,741.2
3,431.2
1.92
12,678.4
3,847.4
8,831.0
3.29
27,814.20 171,616.0 229,894.0 454,967.0
13,317.2 118,868.0 118,946.8 259,398.8
14,497.0 52,748.0 110,947.2 195,568.2
2.09 1.44 1.93 1.75
a b
Ethical statement This research has been certified by the Research Ethics Committee, Faculty of Nursing and Faculty of Medicine, Chiang Mai University (NONE-2560-05175). Research personnel received the required training and certification to conduct clinical-based research. Declaration of competing interest
One US Dollar equal to 30 Thai Baht. Other required healthcare services, i.e. hospital room services.
The authors declare no conflict of interest in this study.
review. Thus, health care settings should take into consideration in the classification of health care cost. By doing this, it may shed the light on the real cost of health care services, and it may count as innovative approach in the delivery of healthcare services.
Acknowledgment This research project was funded by a grant from the Research Fund, Faculty of Nursing, International University of Chiang Mai, Thailand. The authors thank Dr. Azadeh Stark, University of Texas at Dallas for her helpful technical suggestions.
5. Conclusion
References
The overall growth patterns and weight gain of the preterm infants in the control arm of study and the intervention arm of were similar; however, costs of healthcare services were substantially higher in infants of the control group compared to the intervention group, indicating a higher volume of healthcare services and clinical interventions. Findings from our study suggest that maternal participation in the delivery of preterm infants healthcare services, is an effective approach in reducing the cost of healthcare while maintaining the quality. Larger and longer duration randomized clinical trials are needed for further confirmation of findings. Other outcomes such as bonding, long-term
Altimier, L., Phillips, R.M., 2013. The Neonatal integrative developmental care model: seven neuroprotective core measures for family-centered developmental care. N.born Infant Nurs. Rev. 13 (1), 9–22. Altimier, L., Phillips, R.M., 2016. The Neonatal Integrative Development Care Model: advanced clinical applications of the seven core measures for neuroprotective familycentered developmental care. N.born Infant Nurs. Rev. 16, 230–244. Altimier, L., Warner, B., Eichel, M., Warn, B., Tedeschi, L., Brown, B., 2004. Developmental care: changing the NICU physically and behaviorally to promote patient outcomes and contain costs. Neonatal Intensive Care 17 (2), 35–39. Beheshtipoor, N., Shaker, Z., Edraki, M., Razavi, R., Zare, Z., 2013. The effect of family-
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N. Namprom, et al. based empowerment program on the weight and length of hospital stay of preterm infants in the neonatal intensive care unit. Galen Med. J 2 (3), 114–119. Comert, S., Agzikuru, T., Akin, Y., Telatar, B., Tan, P.D., Ergen, S.G., et al., 2012. The cost analysis of preterm infants from a NICU of a State Hospital in Istanbul. Iran. J. Pediatr. (Engl. Ed.) 22 (2), 185–190. Fenton, T.R., Kim, J.H., 2013. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BioMed Cent. Pediatr. 13, 59. Kenner, C., Loot, J.W., 2014. Comprehensive Neonatal Nursing Care, fifth ed. Springer, New York. Melnyk, B.M., Feinstein, N.F., Alpert-Gillis, L., Fairbanks, E., Crean, H.F., Sinkin, R.A., et al., 2006. Reducing premature infants' length of stay and improving parents' mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit Program: a randomized, controlled trial. Pediatrics 118, e1414–e1427. Namprom, N., Picheansathian, W., Jintrawet, U., Chotibang, J., 2018. The effect of maternal participation in preterm's care and improved short-term growth and neurodevelopment outcomes. J. Neonatal Nurs. 24 (4), 196–202. https://doi.org/10.1016/ j.jnn.2018.03.003. OECD/World Health Organization, 2018. Preterm Birth and Low Birth Weight” in Health at a Glance: Asia/Pacific 2018: Measuring Progress towards Universal Health Coverage. OECD Publishing, Paris. https://doi.org/10.1787/health_glance_ap-201821-en. Retrieve form. Peters, K.L., Rosychuk, R.J., Hendson, L., Cote, J.J., McPherson, C., Tyebkhan, J.M., 2009. Improvement of short- and long-term outcomes for very low birth weight infants: edmonton NIDCAP trial. Pediatrics 124 (4), 1009–1020. Pholanun, P., 2012. Maternal Participation in Caring for Preterm Infants in Neonatal Intensive Care Unit and Related Factors (master’s thesis). Chiang Mai: Graduate schoo,l Chiang Mai University, pp. 131 (in Thai). Sintavanarong, P., 2014. Healthcare system in Thailand: past-present and where is the
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Glossary BPD: Bronchopulmonary Dysplasia DoL: Day of Life HAI: Hospital Acquired Infection IVH: Intraventricular Hemorrhage LoS: Length of Stay MPP: Maternal Participation Program NEC: Necrotizing Enterocolitis NICU: Neonatal Intensive Care Unit PCA: Post-conceptional Age ROP: Retinopathy of Prematurity TPN: Total Parenteral Nutrition g/day: gram per day g/kg/day: gram per kilogram per day $: US dollar
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