1. The Benefit and Value Metric Project Are Your NICU CQI Efforts Successful? How Can We Improve VLBW Infant Outcomes and Efficiency in an Age of Constraints? Joe Kaempf MD, John Zupancic MD, Lian Wang MS Lily Lou MD, Sheree Kuo MD, Anup Katheria MD 12.01.13

2. Is your NICU better* than it was a year ago? Five years ago? 10 years ago? * Improved outcomes, more cost-effective, increasingly proficient

3. Are we promoting health in VLBW infants as measured by all 8 of the major NICU morbidities? Do we use our NICU resources efficiently?

4. It is terrifically difficult for NICU staff to have an objective, inclusive grasp of how their NICU is performing, resources consumed, what areas need attention, including a sense of risk- adjustment, and how VLBW infant outcomes interrelate with each other. The coming challenges of budget constraints in the context of undiminished consumer health expectations require innovative solutions.

5. Traditional QI Better QI Best QI Focuses on one morbidity Focuses on all 8 major VON Includes measures of e.g., a high CLD rate morbidities family satisfaction and long term health and financial outcomes Employs traditional linear Recognizes biologic Measures and manipulates models such as PDSA connectivity and interrelated biologic and 4 Key Habits, fishbone includes additional measures social variables to of total morbidity promote health Includes some measure Allocates resource use of cost wisely to maximize population health within budget limitations Bad to Good Maintain Good Good to Excellent Are we moving this way?

6. Is it possible to answer fundamental NICU quality and cost questions by calculating a clinically relevant, statistically rigorous metric that summarizes a NICU’s overall VLBW infant care?* * And not require additional data collection

7. Value = Benefit/Cost

8. Benefit = The % rate of the 8 major VLBW infant morbidities CLD Grade 3-4 IVH PVL Stage 3-4 ROP Any Late Infection D/C wt <10 th pctl NEC Gastrointestinal Perforation Benefit is the summation of the 8 outcomes weighted equally (100 – Morbidity %).

9. Risk Adjustment Multiple Regression Analysis using well-established demographic and clinical adjusters Gestational Age Birth weight/SGA Inborn v. Outborn Apgar 1 Minute Vaginal vs. C/S Major Birth Defect Gender Singleton vs. Multiple Maternal Race

10. Mortality Adjustment 100% - Mortality Excluding Early Deaths % This adjusts for specific morbidity definitions like CLD and ROP, and palliative care practice variance and referral pattern differences between NICUs

11. Cost = Mean T otal Hospital Length of Stay in Survivors

12. Benefit Metric ** P<0.01 *** P<0.001

13. Benefit Metric Summary of CQI Years 2000-2011 The POD Benefit Metric increased from 721 to 778 The VON Benefit Metric increased from 688 to 727 The POD Benefit Metric was significantly greater than the VON Benefit Metric (and the rate of rise was greater) 4/8 POD NICUs significantly increased their Benefit Metric and none declined

14. Value Metric * P<0.05 ** P<0.01 *** P<0.001 POD > VON P=0.003

15. Value Metric Summary of CQI Years 2000-2011 The POD Value Metric did not change 11.2 to 10.9 The VON Value Metric did not change 10.6 to 10.7 The POD Value Metric was significantly greater than the VON Value Metric 3/8 POD NICUs Value Metric significantly increased 2/8 POD NICUs Value Metric significantly decreased

16. What can we learn from NICUS like Center 5? What if we applied the Benefit and Value Metric calculations to 50-60 NICUs within Districts VIII and IX and identified several NICUs with Center 5 type results? Do these proficient NICUs share common bedside practices, cultural elements, staffing structure, finances, leadership style, ethos, physical plant,..…etc.

17. Much of the low hanging CQI fruit in neonatology has been picked,….but not necessarily digested Examples – NCPAP, gentle ventilation, breast milk, hand washing, PICC bundles, RA resuscitation, feeding protocols,….. Which NICUs have been able to sustain improvement over the years,…..and in multiple VLBW infant morbidities,…..and demonstrating cost efficiency? Answer – We simply do not know. There is not a single publication demonstrating sustained improvement in multiple VLBW infant morbidities with improved financial metrics over time using CQI methodology.