1. The impact of managed clinical networks on place of birth and newborn transfers Chris Gale On behalf of the Neonatal Data Analysis Unit and the Medicines for Neonates Investigator Group

2. Background Neonatal services reorganised in 2003 into managed clinical networks Increase provision of high quality neonatal care No formal mechanism established to evaluate the impact of reorganisation on patient care Among preterm infants: Delivery and initial care at specialised units is associated with improved outcomes (Lasswell 2010) Acute postnatal transfer is associated with adverse outcomes (Mohamed 2010, Towers 2000) Reflected in key aims of 2003 reorganisation Amenable to evaluation

3. Aims Use data, routinely collected by units, to evaluate the effectiveness of reorganisation in managed clinical networks Before and after analysis of the following outcomes: 1.Proportion of preterm babies delivered in neonatal units with the greatest neonatal intensive care experience 2.Proportion of preterm babies undergoing early transfer: before 24 hours of age 3.Proportion of preterm babies undergoing late transfer: between 24 hours and 28 days 4.Proportion of multiple birth sets separated by postnatal transfer

4. Study design Epoch 1: Before reorganisation Extracted from CESDI Project 27/28 1 st September 1998 to 31 st August 2000 Babies born alive at 27/28 gestational weeks Epoch 2: After reorganisation Your data! 1 st January 2009 to 31 st December 2010 Babies admitted to a neonatal unit at 27/28 gestational weeks 1998 2000 2002 20082006 2004 2010 Epoch 1Epoch 2 Reorganisation

5. Data analyses Differences between epochs: Level of neonatal unit at hospital of birth and transfer status χ 2 test Dichotomous outcomes: Level of neonatal unit at hospital of birth (≥2000 vs <2000) and multiple birth sets separated by transfer Risk difference (RD) [95% Confidence Intervals] Odds ratio (OR) [95%CI]

6. Results Epoch 1: Before reorganisation 294 centres providing maternity care No standard definition of neonatal unit level 148 providing >48 hours of ventilation 3522 babies between 27 weeks +0 days to 28 weeks +6 days Epoch 2: After reorganisation Data from 146 of 173 neonatal units in 23 neonatal networks 34 level one, 72 level two, 40 level three units 2919 babies between 27 weeks +0 days to 28 weeks +6 days No clinically important differences in demographic characteristics between epochs

7. Results: Place of birth Epoch 1Epoch 2p-value Days Number of babies % of total Number of babies % of total Hospital of birth categorised by annual number of neonatal intensive care days None1394.000 <0.001 1-49984324.133112.2 500-99967319.346517.1 1000-149965318.731611.6 1500-199955615.928710.5 ≥ 200063118.1132548.6 Missing27-195- Total35222919 Proportion delivered in at hospitals with the highest activity NICU increased significantly: RD of 31% [28%, 23%], OR 4.3 [3.83, 4.82]

8. Categorisation of neonatal units in epoch 2 Annual number of neonatal intensive care days provided in epoch two Number of neonatal units Number of neonatal units (% of total) Level 1 neonatal unit Level 2 neonatal unit Level 3 neonatal unit ≤4993223055 (38%) 500-999229132 (22%) 1000-1499012416 (11%) 1500-199905611 (8%) ≥2000032932 (22%) Total347240146 (100%)

9. Results: Transfers Epoch 1Epoch 2p-value Transfer status Number of babies % of total Number of babies % of total Transfers Not transferred 243474.9191965.7 <0.001 ≤ 24 hours 2357.236012.3 24 hours-28 days 57917.864021.9 Missing 0-0- Total32482919 Significantly greater proportion of babies undergoing both acute and later postnatal transfer between epochs

10. 125 75 50 25 0 100 Postnatal age (days) Number of transfers To higher level unit To lower level unit To equivalent unit Transfers in epoch 2

11. Results: Multiple births separated No significant difference detected between epochs RD 3% [-15%, 8%] OR 0.86 [0.50, 1.46] Epoch 1Epoch 2p-value Multiple birth sets separated by transfer Number of birth sets % of total Number of birth sets % of total Not separated 8067.29170.5 0.57 Separated 3932.83829.5 Total119129

12. Limitations and strengths Limitations Association between reorganisation and outcomes Aggregated data only for epoch one Unable to analyse underlying trends in outcomes Strengths Large numbers National distribution of units in both epochs Unambiguous, clearly defined outcomes Epoch two represents current state of neonatal care in England

13. Summary Following reorganisation 1.Increase in proportion of babies delivered at high volume units In keeping with a key aim of reorganisation Over half of babies still delivered at lower volume neonatal units Room for improvement 2.Increase in acute transfers Key aim of reorganisation not being met 1 in 8 babies undergo transfer within first day: 30% to an equivalent or lower level unit Multiple birth sets continue to be separated by transfer Cot capacity impacting on clinical care Better understanding of the clinical implications transfers

14. Acknowledgements Clinicians and other health professionals contributing high quality data Neonatal Data Analysis Unit Shalini SanthakumaranEugene Statnikov Sridevi Nagarajan Imperial College London Academic Neonatal Medicine NDAU Steering Board Jane Abbott Jacquie Kemp Peter BrocklehurstAzeem Majeed Kate CosteloeNeena Modi Liz DraperAlys Young Deborah AshbyAndrew Wilkinson Stavros Petrou

15. Survival Epoch 1Epoch 2 p-value for difference between epoch 1 and 2 Number of babies % of total Number of babies % of total Survival at 28 days Survived285988.0267793.6 <0.001 Died38912.01826.4 Missing0-60- Total32482919 Significantly higher survival in England in epoch 2 vs epoch 1 RD 5.6% [4.2%, 7.0%], OR 2.00 [1.67, 2.40], p<0.001