Henry Lee, MD

  • Henry Chong Lee
  • “I feel privileged to be involved in a very important part of a family’s life.”

I completed my training in pediatrics and neonatology at Lucile Packard Childrens Hospital Stanford and was largely inspired to become a neonatologist due to the neonatologists here who trained me, many of whom I continue to work with today. I am proud to be associated with such excellent colleagues, physicians, nurses, therapists, and others on the team who are deeply devoted to providing great care to our patients and families.

I feel privileged to be involved in a very important part of a family's life. Often in the neonatal intensive care unit, it can be an unexpected situation that is different from what parents pictured the birth of their child to be like. My hope is that I can get them through that difficult process as gently as possible, providing compassion and hope for the whole family.


Neonatal-Perinatal Medicine

Trabajo y Educación

Formación Profesional

University of Illinois College of Medicine, Chicago, IL, 05/09/1999


Stanford University School of Medicine Registrar, Palo Alto, CA, 06/23/2000


Stanford University School of Medicine Registrar, Palo Alto, CA, 06/30/2002


Lucile Packard Children's Hospital, Palo Alto, CA, 06/30/2007

Certificaciones Médicas

Neonatal-Perinatal Medicine, American Board of Pediatrics

Pediatrics, American Board of Pediatrics



Todo Publicaciones

Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011. The Journal of pediatrics Phibbs, C. S., Schmitt, S. K., Cooper, M., Gould, J. B., Lee, H. C., Profit, J., Lorch, S. A. 2018


OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

View details for DOI 10.1016/j.jpeds.2018.08.041

View details for PubMedID 30297293

Hospital Variation in Utilization and Success of Trial of Labor after A Prior Cesarean. American journal of obstetrics and gynecology Xu, X., Lee, H. C., Lin, H., Lundsberg, L. S., Campbell, K. H., Lipkind, H. S., Pettker, C. M., Illuzzi, J. L. 2018


BACKGROUND: Trial of labor after cesarean delivery (TOLAC) is an effective and safe option for women without contraindications.OBJECTIVES: To examine hospital variation in utilization and success of TOLAC and identify associated institutional characteristics and patient outcomes.STUDY DESIGN: Using linked maternal and newborn hospital discharge records and birth certificate data in 2010-2012 from the state of California, we identified 146,185 term singleton mothers with one prior cesarean delivery and no congenital anomalies or clear contraindications for trial of labor at 249 hospitals. Risk-standardized rates of TOLAC utilization and success were estimated for each hospital after accounting for differences in patient case-mix. Risk for severe maternal and newborn morbidities, as well as maternal and newborn length of stay, were compared between hospitals with high utilization and high success rates of TOLAC and other hospitals. Bivariate analysis was also conducted to examine the association of various institutional characteristics with hospitals' TOLAC utilization and success rates.RESULTS: In the overall sample, 12.5% of women delivered vaginally. After adjusting for patient clinical risk factors, rate of TOLAC use and success varied considerably across hospitals with a median of 35.2% (10th-to-90th percentile range: 10.2-67.1%) and 40.5% (10th-to-90th percentile range: 8.5-81.1%), respectively. Risk-standardized utilization and success rates of TOLAC demonstrated an inverted U-shaped relationship such that low or excessively high TOLAC use was associated with lower success rate. Compared to other births, those delivered at hospitals with above-the-median TOLAC use and success rates had a higher risk for uterine rupture (adjusted risk ratio [aRR] = 2.74, p<0.001), severe newborn respiratory complications (aRR=1.46, p<0.001), and severe newborn neurological complications/trauma (aRR=2.48, p<0.001), but they had a lower risk for severe newborn infection (aRR=0.80, p=0.003) and overall severe unexpected newborn complications (aRR=0.86, p<0.001), as well as shorter length of stays (adjusted mean ratio = 0.948 for mothers and 0.924 for newborns, p<0.001 for both). Teaching status, system affiliation, larger volume, higher neonatal care capacity, anesthesia availability, higher proportion of midwife-attended births, and lower proportion of Medicaid or uninsured patients were positively associated with both utilization and success of TOLAC. However, rural location and higher local malpractice insurance premium was negatively associated with TOLAC utilization, whereas for-profit ownership was associated with lower success rate.CONCLUSIONS: Utilization and success rates of TOLAC varied considerably across hospitals. Strategies to promote vaginal birth should be tailored to hospital needs and characteristics (e.g., increase availability at low TOLAC rate hospitals while being more selective at high TOLAC rate hospitals, and targeted support for lower capacity hospitals).

View details for DOI 10.1016/j.ajog.2018.09.034

View details for PubMedID 30278176

Variations in Neonatal Antibiotic Use PEDIATRICS Schulman, J., Profit, J., Lee, H. C., Duenas, G., Bennett, M. V., Parucha, J., Jocson, M. L., Gould, J. B. 2018; 142 (3)


We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens.In a retrospective cohort study of >54000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts.By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume ( = 0.53; P = .01), mortality rate ( = 0.57; P = .004), and average length of stay ( = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%).Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

View details for DOI 10.1542/peds.2018-0115

View details for Web of Science ID 000445687600021

View details for PubMedID 30177514

Gaining Perspectives on Patient and Family Disease Experiences by Storytelling ACADEMIC PEDIATRICS Chandrasekar, H., Harte, S., Sherman, J., Park, K. T., Lee, H. C. 2018; 18 (4): 47576
Maternal body mass index and risk of intraventricular hemorrhage in preterm infants. Pediatric research Pai, V. V., Carmichael, S. L., Kan, P., Leonard, S. A., Lee, H. C. 2018


BACKGROUND: Intraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.METHODS: Population-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.RESULTS: Among 20,927 infants, 4,818 (23%) had IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% CI 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P<0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).CONCLUSION: Pre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand contributing maternal factors.Pediatric Research accepted article preview online, 06 April 2018. doi:10.1038/pr.2018.47.

View details for DOI 10.1038/pr.2018.47

View details for PubMedID 29624572

Parents' Knowledge and Education of Retinopathy of Prematurity in Four California Neonatal Intensive Care Units. American journal of ophthalmology Eneriz-Wiemer, M., Liu, S., Chu, M. C., Uribe-Leitz, T., Rajani, K., Sankar, M., Robbins, S. L., Lee, H. C., Woodard, C., Wang, C. J. 2018


PURPOSE: Retinopathy of prematurity (ROP) may cause visual impairment in infants with very low birth weight. Lack of parent knowledge may contribute to gaps in screening and treatment. We studied parents' knowledge and education of ROP.DESIGN: Cross-sectional study.METHODS: SETTING: Four high-acuity neonatal intensive care units in California (40-84 beds).PARTICIPANTS: 194 English- and Spanish-speaking parents of very low birth weight (<1,500 grams) infants recruited from September 2013 to April 2015.MAIN OUTCOME MEASURES: We asked parents what they knew about ROP, how they were educated about ROP, and their experiences obtaining outpatient eye care. We used multivariate analysis to assess whether parent knowledge was associated with level of English proficiency and literacy, education modality (verbal, written, online, video), and hospital transfer status.RESULTS: 131 (68%) completed surveys: 18% had both limited English proficiency and low literacy while overall 26% had limited English proficiency and 37% had low literacy; 17% did not know that ROP is an eye disease, and 38% did not know that very low birth weight and prematurity are both risk factors for ROP. Parents reported receiving verbal (62%) or written (56%) information; few used online resources (12%) and/or videos (3%). Half reported receiving information about infants' retinopathy status at discharge. No education modality was associated with higher knowledge. Limited English proficiency and low literacy were associated with lower knowledge (versus English-proficient, literate).CONCLUSIONS: Parents of infants with very low birth weight, particularly those with limited English proficiency and low health literacy, lack knowledge about ROP.

View details for DOI 10.1016/j.ajo.2018.03.039

View details for PubMedID 29621506

A directory for neonatal intensive care: potential for facilitating network-based research in neonatology. Journal of perinatology : official journal of the California Perinatal Association Ariagno, R. L., Lee, H. C., Stevenson, D. K., Benjamin, D. K., Smith, P. B., Escobedo, M. B., Bhatt, D. R. 2018


Directories of contact information have evolved over time from thick paperback times such as the "Yellow Pages" to electronic forms that are searchable and have other functionalities. In our clinical specialty, the development of a professional directory helped to promote collaboration in clinical care, education, and quality improvement. However, there are opportunities for increasing the utility of the directory by taking advantage of modern web-based tools, and expanding the use of the directory to fill a gap in the area of collaborative research.

View details for DOI 10.1038/s41372-018-0097-8

View details for PubMedID 29545621

Effect of Maternal Body Mass Index on Postpartum Hemorrhage. Anesthesiology Butwick, A. J., Abreo, A., Bateman, B. T., Lee, H. C., El-Sayed, Y. Y., Stephansson, O., Flood, P. 2018


It is unclear whether obesity is a risk factor for postpartum hemorrhage. The authors hypothesized that obese women are at greater risk of hemorrhage than women with a normal body mass index.The authors conducted a cohort study of women who underwent delivery hospitalization in California between 2008 and 2012. Using multilevel regression, the authors examined the relationships between body mass index with hemorrhage (primary outcome), atonic hemorrhage, and severe hemorrhage (secondary outcomes). Stratified analyses were performed according to delivery mode.The absolute event rate for hemorrhage was 60,604/2,176,673 (2.8%). In this cohort, 4% of women were underweight, 49.1% of women were normal body mass index, 25.9% of women were overweight, and 12.7%, 5.2%, and 3.1% of women were in obesity class I, II, and III, respectively. Compared to normal body mass index women, the odds of hemorrhage and atonic hemorrhage were modestly increased for overweight women (hemorrhage: adjusted odds ratio [aOR], 1.06; 99% CI, 1.04 to 1.08; atonic hemorrhage: aOR, 1.07; 99% CI, 1.05 to 1.09) and obesity class I (hemorrhage: aOR, 1.08; 99% CI, 1.05 to 1.11; atonic hemorrhage; aOR, 1.11; 99% CI, 1.08 to 1.15). After vaginal delivery, overweight and obese women had up to 19% increased odds of hemorrhage or atonic hemorrhage; whereas, after cesarean delivery, women in any obesity class had up to 14% decreased odds of severe hemorrhage.The authors' findings suggest that, at most, maternal obesity has a modest effect on hemorrhage risk. The direction of the association between hemorrhage and body mass index may differ by delivery mode.

View details for DOI 10.1097/ALN.0000000000002082

View details for PubMedID 29346134

Neonatal Jaundice Rudolph's Pediatrics Pammi, M., Lee, H. C., Suresh, G. K. edited by Kline, M. W., Blaney, S. M., Giardino, A. P., Orange, J. S., Penny, D. J., Schutze, G. E., Shekerdemian, L. S. McGraw-Hill Education / Medical. 2018; 23rd ed.: 261264
Incidence Trends and Risk Factor Variation in Severe Intraventricular Hemorrhage across a Population Based Cohort. The Journal of pediatrics Handley, S. C., Passarella, M., Lee, H. C., Lorch, S. A. 2018


To quantify the current burden of severe intraventricular hemorrhage (IVH), describe time trends in severe IVH, identify IVH-associated risk factors, and determine the contribution of mediating factors.The retrospective cohort included infants 220/7-316/7 weeks of gestation without severe congenital anomalies, born at hospitals in the California Perinatal Quality Care Collaborative between 2005 and 2015. The primary study outcome was severe (grade III or IV) IVH.Of 44 028 infants, 3371 (7.7%) had severe IVH. The incidence of severe IVH decreased significantly across California from 9.7% in 2005 to 5.9% in 2015. After stratification by gestational age, antenatal steroid exposure was the only factor associated with a decreased odds of severe IVH for all gestational age subgroups. Other factors, including delivery room intubation, were associated with an increased odds of severe IVH, though significance varied by gestational age. Factors analyzed in the mediation analysis accounted for 45.6% (95% CI 38.7%-71.8%) of the reduction in severe IVH, with increased antenatal steroid administration and decreased delivery room intubation mediating a significant proportion of this decrease, 19.4% (95% CI 13.9%-27.5%) and 27.3% (95% CI 20.3%-39.2%), respectively. The unaccounted proportion varied by gestational age.The incidence of severe IVH decreased across California, associated with changes in antenatal steroid exposure and delivery room intubation. Maternal, patient, and delivery room factors accounted for less than one-half of the decrease in severe IVH. Study of other factors, specifically neonatal intensive care unit and hospital-level factors, may provide new insights into policies to reduce severe IVH.

View details for DOI 10.1016/j.jpeds.2018.04.020

View details for PubMedID 29754865

A Qualitative Analysis of Challenges and Successes in Retinopathy of Prematurity Screening. AJP reports Bain, L. C., Kristensen-Cabrera, A. I., Lee, H. C. 2018; 8 (2): e128e133


Objective The objective of this study is to identify characteristics of neonatal intensive care unit (NICU) practice that influence successful retinopathy of prematurity (ROP) screening. Study Design In this qualitative study, top, improved, and bottom performing NICUs in the California Perinatal Quality Care Collaborative were identified based on ROP screening rates and invited to participate. NICU personnel were interviewed using a semistructured questionnaire. Using thematic analysis, key factors that influence ROP screening were identified. Results Themes found in top performing hospitals include a commitment to quality improvement, a committed ophthalmologist, and a system of double checks. Improved NICUs had a common theme of utilizing telemedicine for exams and identification of eligible neonates on admission. The bottom performing hospital struggled with education and identification of eligible neonates and a lack of a dedicated ophthalmologist. Conclusion Structure, culture, education, and commitment all contribute to the success of ROP screening in the NICU.

View details for DOI 10.1055/s-0038-1660519

View details for PubMedID 29896443

View details for PubMedCentralID PMC5995725

Comparison of Collaborative Versus Single-Site Quality Improvement to Reduce NICU Length of Stay. Pediatrics Lee, H. C., Bennett, M. V., Crockett, M., Crowe, R., Gwiazdowski, S. G., Keller, H., Kurtin, P., Kuzniewicz, M., Mazzeo, A. M., Schulman, J., Nisbet, C. C., Sharek, P. J. 2018


There is unexplained variation in length of stay (LOS) across NICUs, suggesting that there may be practices that can optimize LOS.Three groups of NICUs in the California Perinatal Quality Care Collaborative were followed: (1) collaborative centers participating in an 18-month collaborative quality improvement project to optimize LOS for preterm infants; (2) individual centers aiming to optimize LOS; and (3) nonparticipants. Our aim in the collaborative project was to decrease postmenstrual age (PMA) at discharge for infants born between 27 + 0 and <32 weeks' gestational age by 3 days. A secondary outcome was "early discharge," the proportion of infants discharged from the hospital before 36 + 5 weeks' PMA. The balancing measure of readmissions within 72 hours was tracked for the collaborative group.From 2013 to 2015, 8917 infants were cared for in 20 collaborative NICUs, 19 individual project NICUs, and 71 nonparticipants. In the collaborative group, the PMA at discharge decreased from 37.8 to 37.5 weeks (P = .02), and early discharge increased from 31.6% to 41.9% (P = .006). The individual project group had no significant change. Nonparticipants had a decrease in PMA from 37.5 to 37.3 weeks (P = .01) but no significant change in early discharge (39.8% to 43.6%; P = .24). There was no significant change in readmissions over time in the collaborative group.A structured collaborative project that was focused on optimizing LOS led to a 3-day decrease in LOS and was more effective than individualized quality improvement efforts.

View details for DOI 10.1542/peds.2017-1395

View details for PubMedID 29899043

Programmatic and Administrative Barriers to High-Risk Infant Follow-Up Care. American journal of perinatology Tang, B. G., Lee, H. C., Gray, E. E., Gould, J. B., Hintz, S. R. 2018; 35 (10): 94045


This article characterizes programmatic features of a population-based network of high-risk infant follow-up programs and identifies potential challenges associated with attendance from the providers' perspective.A web-based survey of high-risk infant follow-up program directors, coordinators, and providers of a statewide high-risk infant follow-up system. Frequencies and percentages were used to describe the survey responses.Of the 68 high-risk infant follow-up programs in California, 56 (82%) responded to the survey. The first visit no-show rate between 10 and 30% was estimated by 44% of programs with higher no-show rates for subsequent visits. Common strategies to remind families of appointments were phone calls and mailings. Most programs (54%) did not have a strategy to help families who lived distant to the high-risk infant follow-up clinic.High-risk infant follow-up programs may lack resources and effective strategies to enhance follow-up, particularly for those living at a distance.

View details for DOI 10.1055/s-0038-1629899

View details for PubMedID 29439282

Medical Device Design Education ( Design and Technology Education: an International Journal Sherman, J., Lee, H. C., Weiss, M., Kristensen-Cabrera, A. I. 2018; 23 (2): 154-174
Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives. Clinics in perinatology Pai, V. V., Lee, H. C., Profit, J. 2018; 45 (2): 16580


Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

View details for DOI 10.1016/j.clp.2018.01.013

View details for PubMedID 29747881

Point-of-Care Fecal Calprotectin Monitoring in Preterm Infants at Risk for Necrotizing Enterocolitis. The Journal of pediatrics Nakayuenyongsuk, W., Christofferson, M., Stevenson, D. K., Sylvester, K., Lee, H. C., Park, K. T. 2018


To establish baseline trends in fecal calprotectin, a protein excreted into the stool when there is neutrophilic inflammation in the bowel, in infants at risk for necrotizing enterocolitis (NEC).We performed a prospective observational cohort study in infants with a birth weight of <1500 g without existing bowel disease at a level IV neonatal intensive care unit from October 2015 to September 2016. Stools were collected once daily for 30 days or until 32 weeks postmenstrual age and processed using the Fecal Calprotectin High Range Quantitative Quantum Blue assay.In 64 preterm infants, during the first week after birth, 62% of infants had an initial stool sample with high baseline calprotectin levels (200g/g). In assessment of maternal and neonatal risk factors, maternal etiology for preterm birth (ie, eclamplsia or preeclampsia) was the only significant factor associated with high baseline calprotectin level. Two patients in the cohort developed NEC. Calprotectin levels for the entire cohort fluctuated during the observed period but generally increased in the third and fourth weeks after birth.At-risk infants had highly variable fecal calprotectin levels, with maternal causes for preterm birth associated with higher baseline levels. More longitudinal data in infants with NEC are necessary to determine whether acute rises in fecal calprotectin levels prior to clinical diagnosis can be confirmed as a diagnostic or prognostic biomarker.

View details for DOI 10.1016/j.jpeds.2017.12.069

View details for PubMedID 29519542

Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN Lyndon, A., Malana, J., Hedli, L. C., Sherman, J., Lee, H. C. 2018


To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth.Qualitative description using thematic analysis of interview data.Seventeen women ages 29 to 47 years.Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care.Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during riskmoments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety.Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.

View details for DOI 10.1016/j.jogn.2018.02.008

View details for PubMedID 29551397

Health care and societal costs of bronchopulmonary dysplasia NeoReviews Lapcharoensap, W., Lee, H. C., Nyberg, A., Dukhovny, D. 2018; 19 (4): e211-23

View details for DOI 10.1542/neo.19-4-e211

Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California. Obstetrics and gynecology Lundsberg, L. S., Lee, H. C., Dueas, G. V., Gregory, K. D., Grossetta Nardini, H. K., Pettker, C. M., Illuzzi, J. L., Xu, X. 2018; 131 (2): 21423


To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

View details for DOI 10.1097/AOG.0000000000002437

View details for PubMedID 29324608

Network analysis: a novel method for mapping neonatal acute transport patterns in California. Journal of perinatology Kunz, S. N., Zupancic, J. A., Rigdon, J., Phibbs, C. S., Lee, H. C., Gould, J. B., Leskovec, J., Profit, J. 2017; 37 (6): 702-708


The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression.Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001).Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.Journal of Perinatology advance online publication, 23 March 2017; doi:10.1038/jp.2017.20.

View details for DOI 10.1038/jp.2017.20

View details for PubMedID 28333155

Maternal prepregnancy body mass index and risk of bronchopulmonary dysplasia. Pediatric research Carmichael, S. L., Kan, P., Gould, J. B., Stevenson, D. K., Shaw, G. M., Lee, H. C. 2017


BackgroundWe examined the relationship between women's prepregnancy BMI and development of bronchopulmonary dysplasia (BPD) in their preterm offspring, hypothesizing that obesity-associated inflammation may increase risk.MethodsWe studied infants born in California between 2007 and 2011, using linked data from California Perinatal Quality Care Collaborative neonatal intensive care units, hospital discharge, and vital statistics. We included infants with birthweight <1,500g or gestational age at birth of 22-29 weeks. BPD was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age.ResultsAmong 12,621 infants, 4,078 (32%) had BPD. After adjustment for maternal race/ethnicity, age, education, payer source, and infant sex, BMI status underweight I (BMI <16.9, odds ratio (OR) 1.7, 95% confidence interval (CI) 1.3-2.1) and obesity III (BMI 40.0, OR 1.3, 95% CI 1.0-1.6) were associated with an increased risk of BPD. When considering maternal BMI as a continuous variable, a nonlinear association with BPD was observed for male infants and infants delivered at 25-29 weeks of gestational age, but not for other subgroups.ConclusionBoth high and low maternal BMI were associated with increased BPD risk. These findings support the notion that BPD is a multi-factorial disease that may sometimes have its origins in utero and be influenced by maternal inflammation.Pediatric Research advance online publication, 31 May 2017; doi:10.1038/pr.2017.90.

View details for DOI 10.1038/pr.2017.90

View details for PubMedID 28399116

Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017


Background and ObjectiveTeamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. MethodsCross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. ResultsAcross NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p=0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. ConclusionImproving teamwork may be an important element in infection control efforts.

View details for DOI 10.1055/s-0037-1601563

View details for PubMedID 28395366

Variation in quality report viewing by providers and correlation with NICU quality metrics. Journal of perinatology Wahid, N., Bennett, M. V., Gould, J. B., Profit, J., Danielsen, B., Lee, H. C. 2017


To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality.Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts.The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time.Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.44.

View details for DOI 10.1038/jp.2017.44

View details for PubMedID 28383536

Trends in Patent Ductus Arteriosus Diagnosis and Management for Very Low Birth Weight Infants PEDIATRICS Ngo, S., Profit, J., Gould, J. B., Lee, H. C. 2017; 139 (4)


To examine yearly trends of patent ductus arteriosus (PDA) diagnosis and treatment in very low birth weight infants.In this retrospective cohort study of very low birth weight infants (<1500 g) between 2008 and 2014 across 134 California hospitals, we evaluated PDA diagnosis and treatment by year of birth. Infants were either inborn or transferred in within 2 days after delivery and had no congenital abnormalities. Intervention levels for treatment administered to achieve ductal closure were categorized as none, pharmacologic (indomethacin or ibuprofen), both pharmacologic intervention and surgical ligation, or ligation only. Multivariable logistic regression was used to assess risk factors for PDA diagnosis and treatment.PDA was diagnosed in 42.8% (12002/28025) of infants, with a decrease in incidence from 49.2% of 4205 infants born in 2008 to 38.5% of 4001 infants born in 2014. Pharmacologic and/or surgical treatment was given to 30.5% of patients. Between 2008 and 2014, the annual rate of infants who received pharmacologic intervention (30.5% vs 15.7%) or both pharmacologic intervention and surgical ligation (6.9% vs 2.9%) decreased whereas infants who were not treated (60.5% vs 78.3%) or received primary ligation (2.2% vs 3.0%) increased.There is an increasing trend toward not treating patients diagnosed with PDA compared with more intensive treatments: pharmacologic intervention or both pharmacologic intervention and surgical ligation. Possible directions for future study include the impact of these trends on hospital-based and long-term outcomes.

View details for DOI 10.1542/peds.2016-2390

View details for Web of Science ID 000398602400016

View details for PubMedID 28562302

Thematic analysis of barriers and facilitators to implementation of neonatal resuscitation guideline changes JOURNAL OF PERINATOLOGY Lee, H. C., Arora, V., Brown, T., Lyndon, A. 2017; 37 (3): 249-253


To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project.Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general.Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation.Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.Journal of Perinatology advance online publication, 1 December 2016; doi:10.1038/jp.2016.217.

View details for DOI 10.1038/jp.2016.217

View details for Web of Science ID 000395358000007

View details for PubMedID 27906192

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320


To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.210.1%). Healthcare-associated infection rates were 8.35.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 2811% vs 1719% physicians), day shift workers (303% vs 254% night shift) and workers with 5 or more years of service (292% vs 166% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

View details for DOI 10.1038/jp.2016.211

View details for PubMedID 27853320

Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263


ObjectiveThe objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. DesignThis is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). ResultsOf 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p<0.0001), but checklist use was not significantly different (p=0.88). Higher birth volume hospitals had more specialist coverage (p<0.0001), whereas checklist use did not differ (p=0.3). In-house obstetric coverage was associated with lower asphyxia rates (odds ratio: 0.34; 95% confidence interval [CI]: 0.20, 0.58) in a regression model accounting for other providers. Checklist use was not associated with birth asphyxia (odds ratio: 1.12; 95% CI: 0.75, 1.68). ConclusionHigher birth volume and urban hospitals demonstrated greater in-house specialist coverage, but checklist use was similar across all hospitals. Current data suggest that in-house obstetric coverage has greater impact on asphyxia than other specialist coverage or checklist use.

View details for DOI 10.1055/s-0036-1586505

View details for PubMedID 27487231

Utility of third trimester sonographic measurements for predicting SGA in cases of fetal gastroschisis. Journal of perinatology Blumenfeld, Y. J., Do, S., Girsen, A. I., DAVIS, A. S., Hintz, S. R., Desai, A. K., Mansour, T., Merritt, T. A., Oshiro, B. T., El-Sayed, Y. Y., Shamshirsaz, A. A., Lee, H. C. 2017


To assess the accuracy of different sonographic estimated fetal weight (EFW) cutoffs, and combinations of EFW and biometric measurements for predicting small for gestational age (SGA) in fetal gastroschisis.Gastroschisis cases from two centers were included. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated for different EFW cutoffs, as well as EFW and biometric measurement combinations.Seventy gastroschisis cases were analyzed. An EFW<10% had 94% sensitivity, 43% specificity, 33% PPV and 96% NPV for SGA at delivery. Using an EFW cutoff of <5% improved the specificity to 63% and PPV to 41%, but decreased the sensitivity to 88%. Combining an abdominal circumference (AC) or femur length (FL) z-score less than -2 with the total EFW improved the specificity and PPV but decreased the sensitivity.A combination of a small AC or FL along with EFW increases the specificity and PPV, but decreases the sensitivity of predicting SGA.Journal of Perinatology advance online publication, 26 January 2017; doi:10.1038/jp.2016.275.

View details for DOI 10.1038/jp.2016.275

View details for PubMedID 28125100

Opportunities to Foster Efficient Communication in Labor and Delivery Using Simulation. AJP reports Daniels, K., Hamilton, C., Crowe, S., Lipman, S. S., Halamek, L. P., Lee, H. C. 2017; 7 (1): e44-e48


IntroductionCommunication errors are an important contributing factor in adverse outcomes in labor and delivery (L&D) units. The objective of this study was to identify common lapses in verbal communication using simulated obstetrical scenarios and propose alternative formats for communication. MethodsHealth care professionals in L&D participated in three simulated clinical scenarios. Scenarios were recorded and reviewed to identify questions repeated within and across scenarios. Questions that were repeated more than once due to ineffective communication were identified. The frequency with which the questions were asked across simulations was identified. ResultsQuestions were commonly repeated both within and across 27 simulated scenarios. The median number of questions asked was 27 per simulated scenario. Commonly repeated questions focused on three general topics: (1) historical data/information (i.e., estimated gestational age), (2) maternal clinical status (i.e., estimated blood loss), and (3) personnel (i.e., "Has anesthesiologist been called?"). ConclusionInefficient verbal communication exists in the process of transferring information during obstetric emergencies. These findings can inform improved training and development of information displays to improve teamwork and communication. A visual display that can report static historical information and specific dynamic clinical data may facilitate optimal human performance.

View details for DOI 10.1055/s-0037-1599123

View details for PubMedID 28255522

View details for PubMedCentralID PMC5330795

Hospital variation in cost of childbirth and contributing factors: a cross-sectional study. BJOG : an international journal of obstetrics and gynaecology Xu, X., Lee, H. C., Lin, H., Lundsberg, L. S., Pettker, C. M., Lipkind, H. S., Illuzzi, J. L. 2017


To examine hospital variation in cost of childbirth hospitalisations and identify factors that contribute to the variation.Cross-sectional analysis of linked birth certificate and hospital discharge data.Two hundred and twenty hospitals in California delivering 100 births per year.A total of 405 908 nulliparous term singleton vertex births during 2010-2012.Cost of childbirth hospitalisations was compared across hospitals after accounting for differences in patient clinical risk factors. Relative contributions of patient sociodemographic, obstetric intervention, birth attendant and institutional characteristics to variation in cost were assessed by further adjusting for these factors in hierarchical generalised linear models.Cost of childbirth hospitalisation.Median risk-standardised cost of childbirth was $7149 among the hospitals (10th -90th percentile range: $4760-$10,644). Maternal sociodemographic characteristics and type of birth attendant did not explain hospital variation in cost. Adjustment for obstetric interventions overall reduced within-hospital variance by 15.8% (P < 0.001), while adjusting for caesarean delivery alone reduced within-hospital variance by 14.4% (P < 0.001). However, obstetric interventions did not explain between-hospital variation in cost. In contrast, adjustment for institutional characteristics reduced between-hospital variance by 30.3% (P = 0.002). Hospital type of ownership, teaching/urban-rural status, neonatal care capacity and geographic region were most impactful. Risk-standardised cost was positively correlated with risk-standardised rate of severe newborn morbidities (correlation coefficient 0.22, P = 0.001), but not associated with risk-standardised rate of severe maternal morbidities.Cost of childbirth hospitalisations varied widely among hospitals in California. Institutional characteristics significantly contributed to this variation. Higher-cost hospitals did not have better outcomes, suggesting potential opportunities to enhance value in care.Hospitals vary in cost of childbirth. Institutional characteristics significantly contribute to the variation.

View details for DOI 10.1111/1471-0528.15007

View details for PubMedID 29090498

Practices surrounding pulmonary hypertension and bronchopulmonary dysplasia amongst neonatologists caring for premature infants. Journal of perinatology : official journal of the California Perinatal Association Altit, G., Lee, H. C., Hintz, S., Tacy, T. A., Feinstein, J. A., Bhombal, S. 2017


Pulmonary hypertension (PH) is associated with bronchopulmonary dysplasia (BPD). Screening strategies, a thorough investigation of co-morbidities, and multidisciplinary involvement prior to anti-PH medications have been advocated by recent guidelines. We sought to evaluate current practices of neonatologists caring for premature infants with PH.Electronic survey of American Academy of Pediatrics neonatology members.Among 306 neonatologist respondents, 38% had an institutional screening protocol for patients with BPD; 83% screened at 36 weeks for premature neonates on oxygen/mechanical ventilation. In those practicing more than 5 years, 54% noted increasing numbers of premature infants diagnosed with PH. Evaluation for PH in BPD patients included evaluations for micro-aspiration (41%), airways anomalies (29%), and catheterization (10%). Some degree of acquired pulmonary vein stenosis was encountered in 47%. A majority (90%) utilized anti-PH medications during the neonatal hospitalization.Screening for PH in BPD, and subsequent evaluation and management is highly variable.

View details for DOI 10.1038/s41372-017-0025-3

View details for PubMedID 29234146

Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2017


Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.Prospective observational analysis of 18616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

View details for DOI 10.1542/peds.2017-0918

View details for PubMedID 28847984

Short-term costs of preeclampsia to the United States health care system. American journal of obstetrics and gynecology Stevens, W., Shih, T., Incerti, D., Ton, T. G., Lee, H. C., Peneva, D., Macones, G. A., Sibai, B. M., Jena, A. B. 2017


Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States.This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in2012.We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set.Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age.In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

View details for DOI 10.1016/j.ajog.2017.04.032

View details for PubMedID 28708975

Tackling Quality Improvement in the Delivery Room. Clinics in perinatology Lapcharoensap, W., Lee, H. C. 2017; 44 (3): 66381


Implementation of standardized practices in the delivery room fosters a safe environment to ensure that newborn infants are cared for optimally, whether or not they require extensive resuscitation. Quality improvement (QI) is an excellent methodology for implementation of standardized practices due to the multidisciplinary nature of the delivery room, complexity of tasks involved, and opportunities to track processes and outcomes. This article discusses how the delivery room is a unique environment and presents examples on how to approach delivery room QI. Key areas of potential focus for teams pursuing delivery QI include thermal regulation, optimizing respiratory support, and facilitating team communication.

View details for DOI 10.1016/j.clp.2017.05.003

View details for PubMedID 28802345

Alistair G.S. Philip, MD: Mentor, Teacher, Colleague, Friend NeoReviews Stevenson, D. K., Hay, W. W., Lee, H. C., Wong, R. J. 2017; 18 (12)

View details for DOI 10.1542/neo.18-12-e688

The Effect of Level of Care on Gastroschisis Outcomes. The Journal of pediatrics Apfeld, J. C., Kastenberg, Z. J., Sylvester, K. G., Lee, H. C. 2017; 190: 7984.e1


To examine the relationship between level of care in neonatal intensive care units (NICUs) and outcomes for newborns with gastroschisis.A retrospective cohort study was conducted at 130 California Perinatal Quality Care Collaborative NICUs from 2008 to 2014. All gastroschisis births were examined according to American Academy of Pediatrics NICU level of care at the birth hospital. Multivariate analyses examined odds of mortality, duration of mechanical ventilation, and duration of stay.For 1588 newborns with gastroschisis, the adjusted odds of death were higher for those born into a center with a level IIA/B NICU (OR, 6.66; P=.004), a level IIIA NICU (OR, 5.95; P=.008), or a level IIIB NICU (OR, 5.85; P=.002), when compared with level IIIC centers. The odds of having more days on ventilation were significantly higher for births at IIA/B and IIIB centers (OR, 2.05 [P<.001] and OR, 1.91 [P<.001], respectively). The odds of having longer duration of stay were significantly higher at IIA/B and IIIB centers (OR, 1.71 [P<.004]; OR, 1.77 [P<.001]).NICU level of care was associated with significant disparities in odds of mortality for newborns with gastroschisis.

View details for DOI 10.1016/j.jpeds.2017.07.008

View details for PubMedID 29144275

Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity. JAMA pediatrics Schulman, J., Braun, D., Lee, H. C., Profit, J., Duenas, G., Bennett, M. V., Dimand, R. J., Jocson, M., Gould, J. B. 2017


Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission.To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care.Cross-sectional study of 35921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity.Live birth at GA of 34 weeks or more.Inborn NICU admission rate.Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman =-0.3034, P<.001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman =-0.21, P=.41).Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

View details for DOI 10.1001/jamapediatrics.2017.3913

View details for PubMedID 29181499

Opportunities for maternal transport for delivery of very low birth weight infants JOURNAL OF PERINATOLOGY Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2017; 37 (1): 32-35


To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1508143 births, 13919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

View details for DOI 10.1038/jp.2016.174

View details for Web of Science ID 000391517000007

Variation in Hospital Intrapartum Practices and Association With Cesarean Rate JOGNN-JOURNAL OF OBSTETRIC GYNECOLOGIC AND NEONATAL NURSING Lundsberg, L. S., Illuzzi, J. L., Gariepy, A. M., Sheth, S. S., Pettker, C. M., Lee, H. C., Lipkind, H. S., Xu, X. 2017; 46 (1): 5-17


To examine hospital variation in intrapartum care and its relationship with cesarean rates.Cross-sectional survey.Connecticut and Massachusetts hospitals providing obstetric services.Nurse managers or other clinical staff knowledgeable about intrapartum care.We assessed labor and birth unit capacity and staffing, fetal monitoring, labor management, intrapartum interventions, newborn care, quality assurance, and performance review practices. Association of hospital characteristics and intrapartum practices with cesarean rate was evaluated using Wilcoxon exact rank sum test and Kendall's tau-b correlation coefficient.Among 60 eligible hospitals, respondents from 39 hospitals (65%) completed the survey. Cesarean rates varied from 21%to 42%(median= 30%). Regular review of cesarean rates and indications (85%), regular provision of feedback on cesarean rates and indications to physicians (80%), and regular review of vaginal birth after cesarean rates (94%) were commonly performed at responding hospitals. These practices, however, were not associated with hospital cesarean rate. Hospitals that offered cesarean at the request of the woman (p< .01) and had more liberal indications for labor induction (p< .01) and cesarean birth (p< .01) had significantly greater cesarean rates than institutions without these practices. Routinely placing an intravenous line (p< .01) and drawing blood for complete blood count/type and antibody screen (p< .01) in low-risk women were associated with greater cesarean rates; having a certified nurse-midwife in house at all times (p= .01) and permitting women to eat during labor (p= .02) were associated with lower cesarean rates.Intrapartum practices of hospitals varied markedly. These different patterns of care may suggest differing levels of intrapartum intervention.

View details for DOI 10.1016/j.jogn.2016.07.011

View details for Web of Science ID 000396438700006

View details for PubMedID 27886948

Effects of delivery room quality improvement on premature infant outcomes. Journal of perinatology Lapcharoensap, W., Bennett, M. V., Powers, R. J., Finer, N. N., Halamek, L. P., Gould, J. B., Sharek, P. J., Lee, H. C. 2016


Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight 1500g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.Journal of Perinatology advance online publication, 22 December 2016; doi:10.1038/jp.2016.237.

View details for DOI 10.1038/jp.2016.237

View details for PubMedID 28005062

Characteristics of neonatal transports in California JOURNAL OF PERINATOLOGY Akula, V. P., Gould, J. B., Kan, P., Bollman, L., Profit, J., Lee, H. C. 2016; 36 (12): 1122-1127


To describe the current scope of neonatal inter-facility transports.California databases were used to characterize infants transported in the first week after birth from 2009 to 2012.Transport of the 22550 neonates was classified as emergent 9383 (41.6%), urgent 8844 (39.2%), scheduled 2082 (9.2%) and other 85 (0.4%). In addition, 2152 (9.5%) were initiated for delivery attendance. Most transports originated from hospitals without a neonatal intensive care unit (68%), with the majority transferred to regional centers (66%). Compared with those born and cared for at the birth hospital, the odds of being transported were higher if the patient's mother was Hispanic, <20 years old, or had a previous C-section. An Apgar score <3 at 10 min of age, cardiac compressions in the delivery room, or major birth defect were also risk factors for neonatal transport.As many neonates receive transport within the first week after birth, there may be opportunities for quality improvement activities in this area.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.102.

View details for DOI 10.1038/jp.2016.102

View details for Web of Science ID 000389735700019

View details for PubMedID 27684413

Comparing NICU teamwork and safety climate across two commonly used survey instruments BMJ QUALITY & SAFETY Profit, J., Lee, H. C., Sharek, P. J., Kan, P., Nisbet, C. C., Thomas, E. J., Etchegaray, J. M., Sexton, B. 2016; 25 (12): 954-961


Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

View details for DOI 10.1136/bmjqs-2014-003924

View details for Web of Science ID 000388323100010

View details for PubMedID 26700545

Update on simulation for the Neonatal Resuscitation Program. Seminars in perinatology Ades, A., Lee, H. C. 2016


The goal of the Neonatal Resuscitation Program is to have a trained provider in neonatal resuscitation at every delivery. The Neonatal Resuscitation Program develops its course content on review of the scientific evidence available for the resuscitation of newborns. Just as importantly, the educational structure and delivery of the course are based on evidence and educational theory. Thus, as simulation became a more accepted model in medical education and evidence was developing suggesting benefit of simulation, the Neonatal Resuscitation Program officially added simulation into its courses in 2010. Simulation-based medical education is now an integral part of the Neonatal Resuscitation Program courses both in teaching the psychomotor skills as well as the teamwork skills needed for effective newborn resuscitations. While there is evidence, as in other fields, suggesting that simulation for teaching newborn resuscitation is beneficial whether using high- or low-technology manikins or video-assisted debriefing or not, there are still many unanswered questions as to best practice and patient outcome effects.

View details for DOI 10.1053/j.semperi.2016.08.005

View details for PubMedID 27823817

The Relationship of Nosocomial Infection Reduction to Changes in Neonatal Intensive Care Unit Rates of Bronchopulmonary Dysplasia. journal of pediatrics Lapcharoensap, W., Kan, P., Powers, R. J., Shaw, G. M., Stevenson, D. K., Gould, J. B., Wirtschafter, D. D., Lee, H. C. 2016


To examine whether recent reductions in rates of nosocomial infection have contributed to changes in rates of bronchopulmonary dysplasia (BPD) in a population-based cohort.This was a retrospective, population-based cohort study that used the California Perinatal Quality Care Collaborative database from 2006 to 2013. Eligible infants included those less than 30 weeks' gestational age and less than 1500 g who survived to 3 days of life. Primary variables of interest were rates of nosocomial infections and BPD. Adjusted rates of nosocomial infections and BPD from a baseline period (2006-2010) were compared with a later period (2011-2013). The correlation of changes in rates across periods for both variables was assessed by hospital of care.A total of 22 967 infants from 129 hospitals were included in the study. From the first to second time period, the incidence of nosocomial infections declined from 24.7% to 15% and BPD declined from 35% to 30%. Adjusted hospital rates of BPD and nosocomial infections were correlated positively with a calculated 8% reduction of BPD rates attributable to reductions in nosocomial infections.Successful interventions to reduce rates of nosocomial infections may have a positive impact on other comorbidities such as BPD. The prevention of nosocomial infections should be viewed as a significant component in avoiding long-term neonatal morbidities.

View details for DOI 10.1016/j.jpeds.2016.09.030

View details for PubMedID 27742123

Trends in the delivery route of twin pregnancies in the United States, 2006-2013. European journal of obstetrics, gynecology, and reproductive biology Bateni, Z. H., Clark, S. L., Sangi-Haghpeykar, H., Aagaard, K. M., Blumenfeld, Y. J., Ramin, S. M., Lee, H. C., Fox, K. A., Moaddab, A., Shamshirsaz, A. A., Salmanian, B., Hosseinzadeh, P., Racusin, D. A., Erfani, H., Espinoza, J., Dildy, G. A., Belfort, M. A., Shamshirsaz, A. A. 2016; 205: 120-126


To determine the trends of cesarean delivery rate among twin pregnancies from 2006 to 2013.This is a population-based, cross-sectional analysis of twin live births from United State birth data files of the National Center for Health Statistics for calendar years 2006 through 2013. We stratified the population based on the gestational age groups, maternal race/ethnicity, advanced maternal age (AMA) which was defined by age more than 35 years and within the standard birth weight groups (group 1: birth weight 500-1499g, group 2: birth weight 1500-2499g and group 3: birth weight >2500g). We also analyzed the effect of different risk factors for cesarean delivery in twins.There were 1,079,102 infants born of twin gestations in the U.S. from 2006 to 2013, representing a small but significant increase in the proportion of twin births among all births (3.2% in 2006 versus 3.4% in 2013). The rate of cesarean delivery in twin live births peaked at 75.3% in 2009, and was significantly lower (74.8%) in 2013. The rate of the twin live birth with the breech presentation increased steadily from 26.3% in 2006 to 29.1% in 2013. For the fetus of the twin pregnancy presented as breech, the cesarean delivery rate peaked at 92.2% in 2010, falling slightly but significantly in the ensuing 3 years. The results demonstrated that the decrease in cesarean delivery rate was due to fewer cesareans in non-Hispanic white patients; all other ethnic subgroups showed increasing rates of cesarean delivery throughout the study. Gestational diabetes, gestational hypertension, previous cesarean delivery and breech presentation were all significant risk factors for cesarean delivery during the entire study period. Induction of labor and premature rupture of the membranes were associated with lower rates of cesarean delivery in twins.The recent decrease in the cesarean delivery rate in twin gestation appears to be largely attributable to a decline in cesarean among pregnancies complicated by breech presentation in non-Hispanic white women, and may reflect a health care disparity that deserves further research.

View details for DOI 10.1016/j.ejogrb.2016.08.031

View details for PubMedID 27591713

Case 1: Constipation, Irritability, and Poor Feeding in 2-month-old Boy. Pediatrics in review Shah, N. A., Lee, H. C. 2016; 37 (9): 391-393

View details for DOI 10.1542/pir.2014-0114

View details for PubMedID 27587641

Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight. Academic pediatrics Eneriz-Wiemer, M., Saynina, O., Sundaram, V., Lee, H. C., Bhattacharya, J., Sanders, L. M. 2016; 16 (7): 645-652


Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age 32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P=.008) and completed 8% more preventive visits (95% confidence interval 1-64, P=.019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

View details for DOI 10.1016/j.acap.2016.04.004

View details for PubMedID 27130810

Inhaled nitric oxide use in preterm infants in California neonatal intensive care units. Journal of perinatology Handley, S. C., Steinhorn, R. H., Hopper, A. O., Govindaswami, B., BHATT, D. R., Van Meurs, K. P., Ariagno, R. L., Gould, J. B., Lee, H. C. 2016; 36 (8): 635-639


To describe inhaled nitric oxide (iNO) exposure in preterm infants and variation in neonatal intensive care unit (NICU) use.This was a retrospective cohort study of infants, 22 to 33+6/7 weeks of gestational age (GA), during 2005 to 2013. Analyses were stratified by GA and included population characteristics, iNO use over time and hospital variation.Of the 65824 infants, 1718 (2.61%) received iNO. Infants, 22 to 24+6/7 weeks of GA, had the highest incidence of iNO exposure (6.54%). Community NICUs (n=77, median hospital use rate 0.7%) used less iNO than regional NICUs (n=23, median hospital use rate 5.8%). In 22 to 24+6/7 weeks of GA infants, the median rate in regional centers was 10.6% (hospital interquartile range 3.8% to 22.6%).iNO exposure varied with GA and hospital level, with the most use in extremely premature infants and regional centers. Variation reflects a lack of consensus regarding the appropriate use of iNO for preterm infants.Journal of Perinatology advance online publication, 31 March 2016; doi:10.1038/jp.2016.49.

View details for DOI 10.1038/jp.2016.49

View details for PubMedID 27031320

Perceived Factors Associated with Sustained Improvement Following Participation in a Multicenter Quality Improvement Collaborative. Joint Commission journal on quality and patient safety / Joint Commission Resources Stone, S., Lee, H. C., Sharek, P. J. 2016; 42 (7): 309-315


The California Perinatal Quality Care Collaborative led the Breastmilk Nutrition Quality Improvement Collaborative from October 2009 to September 2010 to increase the percentage of very low birth weight infants receiving breast milk at discharge in 11 collaborative neonatal ICUs (NICUs). Observed increases in breast milk feeding and decreases in necrotizing enterocolitis persisted for 6 months after the collaborative ended. Eighteen to 24 months after the end of the collaborative, some sites maintained or further increased their gains, while others trended back toward baseline. A study was conducted to assess the qualitative factors that affect sustained improvement following participation.Collaborative leaders at each of the 11 NICUs that participated in the Breastmilk Nutrition Quality Improvement Collaborative were invited to participate in a site-specific one-hour phone interview. Interviews were recorded and transcribed and then analyzed using qualitative research analysis software to identify themes associated with sustained improvement.Eight of 11 invited centers agreed to participate in the interviews. Thematic saturation was achieved by the sixth interview, so further interviews were not pursued. Factors contributing to sustainability included physician involvement within the multidisciplinary teams, continuous education, incorporation of interventions into the daily work flow, and integration of a data-driven feedback system.Early consideration by site leaders of how to integrate best-practice interventions into the daily work flow, and ensuring physician commitment and ongoing education based in continuous data review, should enhance the likelihood of sustaining improvements. To maximize sustained success, future collaborative design should consider proactively identifying and supporting these factors at participating sites.

View details for PubMedID 27301834

Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B., Profit, J. 2016; 33 (8): 751-757


ObjectiveDevelop length of stay prediction models for neonatal intensive care unit patients. Study DesignWe used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. ResultsOur sample included 23,551 patients. Median length of stay was 79 days when birth weight was<1,000g, 46 days for 1,000 to 1,500g, 21 days for 1,500 to 2,500g, and 8 days for 2,500 g. Risk factors for longer length of stay varied by weight. Units with shorter length of stay for one weight group had shorter lengths of stay for other groups. ConclusionRisk models for comparative assessments of length of stay need to appropriately account for weight, particularly considering the cutoff of 1,500 g. Refining prediction may benefit counseling of families and health care systems to efficiently allocate resources.

View details for DOI 10.1055/s-0036-1572433

View details for Web of Science ID 000378888600005

View details for PubMedID 26890437

Impact of antenatal steroids on intraventricular hemorrhage in very-low-birth weight infants JOURNAL OF PERINATOLOGY Wei, J. C., Catalano, R., Profit, J., Gould, J. B., Lee, H. C. 2016; 36 (5): 352-356


To determine the association between antenatal steroids administration and intraventricular hemorrhage rates.We used cross-sectional data from the California Perinatal Quality Care Collaborative during 2007 to 2013 for infants 32 weeks gestational age. Using multivariable logistic regression, we evaluated the effect of antenatal steroids on intraventricular hemorrhage, stratified by gestational age.In 25979 very-low-birth weight infants, antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage (odds ratio=0.68, 95% confidence interval: 0.62, 0.75) and a reduction in incidence of severe intraventricular hemorrhage (odds ratio=0.51, 95% confidence interval: 0.45, 0.58). This association was seen across gestational ages ranging from 22 to 29 weeks.Although current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation, our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age.

View details for DOI 10.1038/jp.2016.38

View details for Web of Science ID 000374914900006

View details for PubMedID 27010109

The Association of Level of Care With NICU Quality. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2016; 137 (3): 1-9


Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

View details for DOI 10.1542/peds.2014-4210

View details for PubMedID 26908663

Impact of Donor Milk Availability on Breast Milk Use and Necrotizing Enterocolitis Rates. Pediatrics Kantorowska, A., Wei, J. C., Cohen, R. S., Lawrence, R. A., Gould, J. B., Lee, H. C. 2016; 137 (3): 1-8


To examine the availability of donor human milk (DHM) in a population-based cohort and assess whether the availability of DHM was associated with rates of breast milk feeding at NICU discharge and rates of necrotizing enterocolitis (NEC).Individual patient clinical data for very low birth weight infants from the California Perinatal Quality Care Collaborative were linked to hospital-level data on DHM availability from the Mothers' Milk Bank of San Jos for 2007 to 2013. Trends of DHM availability were examined by level of NICU care. Hospitals that transitioned from not having DHM to having DHM availability during the study period were examined to assess changes in rates of breast milk feeding at NICU discharge and NEC.The availability of DHM increased from 27 to 55 hospitals during the study period. The availability increased for all levels of care including regional, community, and intermediate NICUs, with the highest increase occurring in regional NICUs. By 2013, 81.3% of premature infants cared for in regional NICUs had access to DHM. Of the 22 hospitals that had a clear transition to having availability of DHM, there was a 10% increase in breast milk feeding at NICU discharge and a concomitant 2.6% decrease in NEC rates.The availability of DHM has increased over time and has been associated with positive changes including increased breast milk feeding at NICU discharge and decrease in NEC rates.

View details for DOI 10.1542/peds.2015-3123

View details for PubMedID 26908696

Optimal Criteria Survey for Preresuscitation Delivery Room Checklists. American journal of perinatology Brown, T., Tu, J., Profit, J., Gupta, A., Lee, H. C. 2016; 33 (2): 203-207


ObjectiveTo investigate the optimal format and content of delivery room reminder tools, such as checklists. Study DesignVoluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. ResultsFifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. ConclusionsClinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.

View details for DOI 10.1055/s-0035-1564064

View details for PubMedID 26368913

Temperature Management in the Delivery Room and During Neonatal Resuscitation NeoReviews Lapcharoensap, W., Lee, H. C. 2016; 17 (8)

View details for DOI 10.1542/neo.17-8-e454

International Perspectives: Reducing Birth Asphyxia in China by Implementing the Neonatal Resuscitation Program and Helping Babies Breathe Initiative NeoReviews Xu, T., Niermeyer, S., Lee, H. C., Simon, W. M., Yue, Q., Gong, L., Wang, H. 2016; 17 (8)

View details for DOI 10.1542/neo.17-8-e425

Platelet count and associated morbidities in VLBW infants with pharmacologically treated patent ductus arteriosus JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Murphy, D. P., Lee, H. C., Payton, K. S., Powers, R. J. 2016; 29 (13): 2045-2048


Characterize the diagnosis of PDA and the distribution of pretreatment platelet count in pharmacologically managed PDA in infants 1500g and assess the relationship of platelet count to serious morbidities.This is a retrospective, observational study. In 40 hospitals, data were collected on PDA, including pretreatment platelet count. Distribution of platelet count was examined. The association of platelet count and clinical outcomes of IVH, NEC and PDA closure prior to discharge were examined. Chi-square test was used to compare outcomes by platelet count groups.There were 311 patients treated with medically treated PDA. Pretreatment platelet counts were categorized as 0-119K, 120-199K, 200-299K, >300K. Incidence and grade of IVH were not significantly different by platelet group. Across all groups: No IVH 62-83%, Grades 1-2 IVH 13-25%, Grades 3-4 IVH 2-13%. NEC occurred in 0-11% of all patients studied. PDA closure rate was 33-45%.PDA closure was not significantly affected by platelet count. Platelet count was not a statistically significant factor for development of IVH and NEC in infants born <1500g with pharmacologically treated PDA.

View details for DOI 10.3109/14767058.2015.1076785

View details for Web of Science ID 000374773800001

View details for PubMedID 26365622

Postnatal growth failure in very low birthweight infants born between 2005 and 2012. Archives of disease in childhood. Fetal and neonatal edition Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2016; 101 (1): 50-55


Postnatal growth restriction is common in preterm infants and is associated with long-term neurodevelopmental impairment. Recent trends in postnatal growth restriction are unclear.Birth and discharge weights from 25899 Californian very low birthweight infants (birth weight 500-1500g, gestational age 22-32weeks) who were born between 2005 and 2012 were converted to age-specific Z-scores and analysed using multivariable modelling.Birthweight Z-score did not change between 2005 and 2012. However, the adjusted discharge weight Z-score increased significantly by 0.168 Z-scores (0.154, 0.182) over the study period, and the adjusted fall in weight Z-score between birth and discharge decreased significantly between those dates (by 0.016 Z-scores/year). The proportion of infants who were discharged home below the 10th weight-for-age centile or had a fall in weight Z-score between birth and discharge of >1 decreased significantly over time. The comorbidities most associated with poorer postnatal growth were medical or surgical necrotising enterocolitis, isolated gastrointestinal perforation and severe retinopathy of prematurity, which were associated with an adjusted mean reduction in discharge weight Z-score of 0.24, 0.57, 0.46 and 0.32, respectively. Chronic lung disease was not a risk factor after accounting for length of stay.Postnatal, but not prenatal, growth improved among very low birthweight infants between 2005 and 2012. Neonatal morbidities including necrotising enterocolitis, gastrointestinal perforations and severe retinopathy of prematurity have significant negative effects on postnatal growth.

View details for DOI 10.1136/archdischild-2014-308095

View details for PubMedID 26201534

Effect of Catheter Dwell Time on Risk of Central Line-Associated Bloodstream Infection in Infants PEDIATRICS Greenberg, R. G., Cochran, K. M., Smith, P. B., Edson, B. S., Schulman, J., Lee, H. C., Govindaswami, B., Pantoja, A., Hardy, D., Curran, J., Lin, D., Kuo, S., Noguchi, A., Ittmann, P., Duncan, S., Gupta, M., Picarillo, A., Karna, P., Cohen, M., Giuliano, M., Carroll, S., Page, B., Guzman-Cottrill, J., Walker, M. W., Garland, J., Ancona, J. K., Ellsbury, D. L., Laughon, M. M., McCaffrey, M. J. 2015; 136 (6): 1080-1086


Central venous catheters in the NICU are associated with significant morbidity and mortality because of the risk of central line-associated bloodstream infections (CLABSIs). The purpose of this study was to determine the effect of catheter dwell time on risk of CLABSI.Retrospective cohort study of 13,327 infants with 15,567 catheters (93% peripherally inserted central catheters [PICCs], 7% tunneled catheters) and 256,088 catheter days cared for in 141 NICUs. CLABSI was defined using National Health Surveillance Network criteria. We defined dwell time as the number of days from line insertion until either line removal or day of CLABSI. We generated survival curves for each week of dwell time and estimated hazard ratios for CLABSI at each week by using a Cox proportional hazards frailty model. We controlled for postmenstrual age and year, included facility as a random effect, and generated separate models by line type.Median postmenstrual age was 29 weeks (interquartile range 26-33). The overall incidence of CLABSI was 0.93 per 1000 catheter days. Increased dwell time was not associated with increased risk of CLABSI for PICCs. For tunneled catheters, infection incidence was significantly higher in weeks 7 and 9 compared with week 1.Clinicians should not routinely replace uninfected PICCs for fear of infection but should consider removing tunneled catheters before week 7 if no longer needed. Additional studies are needed to determine what daily maintenance practices may be associated with decreased risk of infection, especially for tunneled catheters.

View details for DOI 10.1542/peds.2015-0573

View details for Web of Science ID 000370254400040

View details for PubMedID 26574587

View details for PubMedCentralID PMC4657598

Effect of time of birth on maternal morbidity during childbirth hospitalization in California. American journal of obstetrics and gynecology Lyndon, A., Lee, H. C., Gay, C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2015; 213 (5): 705 e1-705 e11


This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization.Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models.The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjustedodds ratio [AOR], 1101-1500= 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900= 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300= 1.31; 95% CI, 1.21-1.41; 0301-0700 =1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday= 1.00; 95% CI, 0.98-1.02]; Sunday= 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday= 1.09; 95% CI, 1.00-1.18; Sunday= 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity.Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.

View details for DOI 10.1016/j.ajog.2015.07.018

View details for PubMedID 26196454

View details for PubMedCentralID PMC4631702

Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (Reprint). Pediatrics Perlman, J. M., Wyllie, J., Kattwinkel, J., Wyckoff, M. H., Aziz, K., Guinsburg, R., Kim, H., Liley, H. G., Mildenhall, L., Simon, W. M., Szyld, E., Tamura, M., Velaphi, S. 2015; 136: S120-66

View details for DOI 10.1542/peds.2015-3373D

View details for PubMedID 26471381

Effects of race/ethnicity and BMI on the association between height and risk for spontaneous preterm birth AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Shachar, B. Z., Mayo, J. A., Lee, H. C., Carmichael, S. L., Stevenson, D. K., Shaw, G. M., Gould, J. B. 2015; 213 (5)

View details for DOI 10.1016/j.ajog.2015.07.005

View details for Web of Science ID 000365763400027

View details for PubMedID 26187451

Multimodality Renal Failure in a Patient with OEIS Complex. AJP reports Santoro, J. D., Chao, S., Hsieh, M. H., Lee, H. C. 2015; 5 (2): e161-4


Omphalocele-exstrophy of the bladder-imperforate anus-spinal defect (OEIS) complex is a rare constellation of clinical abnormalities with wide phenotypic presentation. We describe a case of a preterm neonate with OEIS complex with acute renal failure, and the challenges in diagnosis and management of this patient as renal failure can be a multifactorial process when encountered with this rare complex.

View details for DOI 10.1055/s-0035-1554799

View details for PubMedID 26495176

View details for PubMedCentralID PMC4603852

Neonatal resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations RESUSCITATION Wyllie, J., Perlman, J. M., Kattwinkel, J., Wyckoff, M. H., Aziz, K., Guinsburg, R., Kim, H., Liley, H. G., Mildenhall, L., Simon, W. M., Szyld, E., Tamura, M., Velaphi, S. 2015; 95: E169-E201
Maternal Asthma, Preterm Birth, and Risk of Bronchopulmonary Dysplasia. journal of pediatrics Gage, S., Kan, P., Lee, H. C., Gould, J. B., Stevenson, D. K., Shaw, G. M., O'Brodovich, H. M. 2015; 167 (4): 875-880 e1


To study the relationship between maternal asthma and the development of bronchopulmonary dysplasia (BPD).Using a large population-based California cohort, we investigated associations between maternal asthma and preterm birth subtype, as well as maternal asthma and BPD. We used data from 2007-2010 maternal delivery discharge records of 2009511 pregnancies and International Classification of Diseases, Ninth Revision codes. Preterm birth was defined as <37weeks gestational age (GA), with subgroups of <28weeks, 28-32weeks, and 33-37weeksGA, as well as preterm subtype, defined as spontaneous, medically indicated, or unknown. Linkage between the 2 California-wide datasets yielded 21944 singleton preterm infants linked to their mother's records, allowing estimation of the risk of BPD in mothers with asthma and those without asthma.Maternal asthma was associated with increased odds (OR, 1.42; 95% CI, 1.38-1.46) of preterm birth at <37weeksGA, with the greatest risk for 28-32GA (aOR, 1.60; 95% CI, 1.47-1.74). Among 21944 preterm infants, we did not observe an elevated risk for BPD in infants born to mothers with asthma (aOR, 1.03; 95% CI, 0.9-1.2). Stratification by maternal treatment with antenatal steroids revealed increased odds of BPD in infants whose mothers had asthma but did not receive antenatal steroids (aOR, 1.54; 95% CI, 1.15-2.06), but not in infants whose mothers had asthma and were treated with antenatal steroids (aOR, 0.85; 95% CI, 0.67-1.07).Asthma in mothers who did not receive antenatal steroid treatment is associated with an increased risk of BPD in their preterm infants.

View details for DOI 10.1016/j.jpeds.2015.06.048

View details for PubMedID 26254835

Neonatal Intensive Care Unit Antibiotic Use PEDIATRICS Schulman, J., Dimand, R. J., Lee, H. C., Duenas, G. V., Bennett, M. V., Gould, J. B. 2015; 135 (5): 826-833


Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay.In a retrospective cohort study of 52061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

View details for DOI 10.1542/peds.2014-3409

View details for Web of Science ID 000353728400044

View details for PubMedID 25896845

Obstetric Ultrasound Quality Improvement Initiative-Utilization of a Quality Assurance Process and Standardized Checklists AMERICAN JOURNAL OF PERINATOLOGY Mrazek-Pugh, B., Blumenfeld, Y. J., Lee, H. C., Chueh, J. 2015; 32 (6): 599-604


ObjectiveOur aim was to assess whether mandated completion of an electronic checklist and a quality assurance (QA) process improved obstetric (OB) ultrasound image documentation. Study DesignA checklist of mandated images based on the American Institute of Ultrasound in Medicine guidelines was created. A baseline QA assessment was performed with a lead senior sonographer reviewing eight random OB examinations for each sonographer. An electronic checklist was then instituted for all OB examinations on each ultrasound machine. It was mandated that each anatomical structure be checked off during real-time image acquisition. A repeat QA assessment of each sonographer was then performed quarterly. ResultsBaseline assessments were performed between September 2011 and November 2011. Out of the 110 examinations analyzed, only 49% were deemed "complete" with none of the sonographers having a 100% complete examination rate. Following institution of the mandated electronic checklist, a repeat assessment revealed an 81% complete examination rate for the next quarter, and 90% were complete at the end of a year. All sonographers improved their image acquisition regardless of baseline skill level at the initial QA. ConclusionA QA process and a mandated standardized electronic checklist improved the image documentation.

View details for DOI 10.1055/s-0035-1545667

View details for Web of Science ID 000354342400013

View details for PubMedID 25730132

Correlation of continuous glucose monitoring profiles with pregnancy outcomes in nondiabetic women. American journal of perinatology Sung, J. F., Kogut, E. A., Lee, H. C., Mannan, J. L., Navabi, K., Taslimi, M. M., El-Sayed, Y. Y. 2015; 32 (5): 461-468


ObjectiveTo determine whether hyperglycemic excursions detected by continuous glucose monitoring (CGM) correlate with birth weight percentile and other pregnancy outcomes, and whether CGM correlates better with these outcomes than a single glucose value from a 1-hour glucose challenge test (GCT). Study DesignThis was a prospective observational study of 55 pregnant patients without preexisting diabetes, who wore a CGM device for up to 7 days, between 24 and 28 weeks' gestation. The area under the curve (AUC) of hyperglycemic excursions above various thresholds (110, 120, 130, 140, and 180 mg/dL) was calculated. These AUC values, and results from a standard 50-g GCT, were correlated with our primary outcome of birth weight percentile, and secondary outcomes of unplanned operative delivery, pregnancy complications, delivery complications, fetal complications, and neonatal complications. ResultsA consistent correlation was seen between all AUC thresholds and birth weight percentile (r=0.29, p<0.05 for AUC-110, -120, -130, and -140; r=0.25, p=0.07 for AUC-180). This correlation was stronger than that of 1-hour oral GCT (r=-0.02, p=0.88). There was no association between AUC values and other outcomes. ConclusionsAmong nondiabetic pregnant patients, hyperglycemic excursions detected by CGM show a stronger correlation to birth weight percentile than blood glucose values obtained 1-hour after a 50-g oral GCT.

View details for DOI 10.1055/s-0034-1390344

View details for PubMedID 25262455

Hospital Variation in Medical and Surgical Treatment of Patent Ductus Arteriosus AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Durand, D. J., Danielsen, B., Duenas, G. V., Powers, R. J. 2015; 32 (4): 379-385


ObjectiveThis study aims to characterize population risks for diagnosis, medical treatment, and surgical ligation of patent ductus arteriosus (PDA) in very low-birth-weight infants. Study DesignMaternal and neonatal data were collected in 40 hospitals in California during 2011 for infants with birth weight1,500g without any congenital malformation, with a diagnosis of PDA. Multivariable logistic regression was used to determine independent risks for PDA diagnosis and for surgical ligation. ResultsThere were 770/1,902 (40.4%) infants diagnosed with PDA. Low birth weight, gestational age, respiratory distress syndrome, and surfactant administration were associated with PDA diagnosis. Ligation occurred in 43% of patients with birth weight750g, in 24% of patients weighing between 715 and 1,000g, and in 12% of patients weighing from 1,001 to 1,500 g. Older gestational age (1week, odds ratio 0.55, 95% confidence interval 0.48-0.63) and absence of respiratory distress syndrome (odds ratio 0.14, 95% confidence interval 0.03-0.59) were associated with lower ligation risk. The median hospital ligation rate was 14% (interquartile range 0-38%). ConclusionMost patients with PDA receive treatment for closure. Practice variation may set the stage for further exploration of experimental trials.

View details for DOI 10.1055/s-0034-1387931

View details for Web of Science ID 000351664400011

View details for PubMedID 25241108

Magnesium sulfate exposure and neonatal intensive care unit admission at term. Journal of perinatology Girsen, A. I., Greenberg, M. B., El-Sayed, Y. Y., LEE, H., Carvalho, B., Lyell, D. J. 2015; 35 (3): 181-185


Objective:The aim of this study was to investigate the effect of maternal magnesium sulfate (MgSO4) exposure for eclampsia prophylaxis on neonatal intensive care unit (NICU) admission rates for term newborns.Study Design:A secondary analysis of the Maternal-Fetal Medicine Unit Network Cesarean Registry, including primary and repeat cesarean deliveries, and failed and successful trials of labor after cesarean was conducted. Singleton pregnancies among women with preeclampsia and >37 weeks of gestation were included. Pregnancies with uterine rupture, chorioamnionitis and congenital malformations were excluded. Logistic regression analysis was used to determine associations between MgSO4 exposure and NICU admission. P<0.05 was considered statistically significant.Result:Two thousand one hundred and sixty-six term pregnancies of women with preeclampsia were included, of whom 1747 (81%) received MgSO4 for eclampsia prophylaxis and 419 (19%) did not. NICU admission rates were higher among newborns exposed to MgSO4 vs unexposed (22% vs 12%, P<0.001). After controlling for neonatal birth weight, gestational age and maternal demographic and obstetric factors, NICU admission remained significantly associated with antenatal MgSO4 exposure (adjusted odds ratio 1.9, 95% confidence interval 1.3 to 2.6, P<0.001). Newborns exposed to MgSO4 were more likely to have Apgar scores <7 at 1 and 5min (15% vs 11% unexposed, P=0.01 and 3% vs 0.7% unexposed, P=0.008). There were no significant differences in NICU length of stay (median 5 (range 2 to 91) vs 6 (3 to 15), P=0.5).Conclusion:Antenatal maternal MgSO4 treatment was associated with increased NICU admission rates among exposed term newborns of mothers with preeclampsia. This study highlights the need for studies of maternal MgSO4 administration protocols that optimize maternal and fetal benefits and minimize risks.Journal of Perinatology advance online publication, 16 October 2014; doi:10.1038/jp.2014.184.

View details for DOI 10.1038/jp.2014.184

View details for PubMedID 25321647

Impact of a novel decision support tool on adherence to Neonatal Resuscitation Program algorithm RESUSCITATION Fuerch, J. H., Yamada, N. K., Coelho, P. R., Lee, H. C., Halamek, L. P. 2015; 88: 52-56


Studies have shown that healthcare professionals (HCPs) display a 16-55% error rate in adherence to the Neonatal Resuscitation Program (NRP) algorithm. The aim of this study was to evaluate adherence to the Neonatal Resuscitation Program algorithm by subjects working from memory as compared to subjects using a decision support tool that provides auditory and visual prompts to guide implementation of the Neonatal Resuscitation Program algorithm during simulated neonatal resuscitation.Healthcare professionals (physicians, nurse practitioners, obstetrical/neonatal nurses) with a current NRP card were randomized to the control or intervention group and performed three simulated neonatal resuscitations. The scenarios were evaluated for the initiation and cessation of positive pressure ventilation (PPV) and chest compressions (CC), as well as the frequency of FiO2 adjustment. The Wilcoxon rank sum test was used to compare a score measuring the adherence of the control and intervention groups to the Neonatal Resuscitation Program algorithm.Sixty-five healthcare professionals were recruited and randomized to the control or intervention group. Positive pressure ventilation was performed correctly 55-80% of the time in the control group vs. 94-95% in the intervention group across all three scenarios (p<0.0001). Chest compressions were performed correctly 71-81% of the time in the control group vs. 82-93% in the intervention group in the two scenarios in which they were indicated (p<0.0001). FiO2 was addressed three times more frequently in the intervention group compared to the control group (p<0.001).Healthcare professionals using a decision support tool exhibit significantly fewer deviations from the Neonatal Resuscitation Program algorithm compared to those working from memory alone during simulated neonatal resuscitation.

View details for DOI 10.1016/j.resuscitation.2014.12.016

View details for Web of Science ID 000352508400023

View details for PubMedID 25555358

Referral of Very Low Birth Weight Infants to High-Risk Follow-Up at Neonatal Intensive Care Unit Discharge Varies Widely across California. journal of pediatrics Hintz, S. R., Gould, J. B., Bennett, M. V., Gray, E. E., Kagawa, K. J., Schulman, J., Murphy, B., Villarin-Duenas, G., Lee, H. C. 2015; 166 (2): 289-295


To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative.Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral.In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; 750 g vs 1251-1499g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment.There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

View details for DOI 10.1016/j.jpeds.2014.10.038

View details for PubMedID 25454311

Regional variation in antenatal corticosteroid use: a network-level quality improvement study. Pediatrics Profit, J., Goldstein, B. A., TAMARESIS, J., Kan, P., Lee, H. C. 2015; 135 (2): e397-404


Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions.We undertook cross-sectional analysis of 33610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect.From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance.We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.

View details for DOI 10.1542/peds.2014-2177

View details for PubMedID 25601974

Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G. M., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)


Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

View details for DOI 10.1001/jamapediatrics.2014.3676

View details for PubMedID 25642906

Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

View details for DOI 10.1001/jamapediatrics.2014.2085

View details for PubMedID 25383940

Part 7: Neonatal Resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation Perlman, J. M., Wyllie, J., Kattwinkel, J., Wyckoff, M. H., Aziz, K., Guinsburg, R., Kim, H. S., Liley, H. G., Mildenhall, L., Simon, W. M., Szyld, E., Tamura, M., Velaphi, S. 2015; 132 (16 Suppl 1): S20441

View details for DOI 10.1161/CIR.0000000000000276

View details for PubMedID 26472855

Protocol for delivery room management of hydrops Neonatology: Clinical Practice and Procedures Gupta, A., Lee, H. C. edited by Stevenson, D. K., Cohen, R. S., Sunshine, P. McGraw Hill Education. 2015: 9991004
The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. Journal of perinatology : official journal of the California Perinatal Association Griffin, I. J., Lee, H. C., Profit, J., Tancedi, D. J. 2015


Objective:Survival of preterm and very low birth weight (VLBW) infants has steadily improved. However, the rates of mortality and morbidity among the very smallest infants are poorly characterized.Study Design:Data from the California Perinatal Quality Care Collaborative for the years 2005 to 2012 were used to compare the mortality and morbidity of profoundly low birth weight (ProLBW, birth weight 300 to 500g) and profoundly small for gestational age (ProSGA, <1st centile for weight-for-age) infants with very low birth weight (VLBW, birth weight 500 to 1500g) and appropriate for gestational age (AGA, 5th to 95th centile for weight-for-age) infants, respectively.Result:Data were available for 44561 neonates of birth weight <1500g. Of these, 1824 were ProLBW and 648 were ProSGA. ProLBW and ProSGA differed in their antenatal risk factors from the comparison groups and were less likely to receive antenatal steroids or to be delivered by cesarean section. Only 14% of ProSGA and 21% of ProLBW infants survived to hospital discharge, compared with >80% of AGA and VLBW infants. The largest increase in mortality in ProSGA and ProLBW infants occurred prior to 12h of age, and most mortality happened in this time period. Survival of the ProLBW and ProSGA infants was positively associated with higher gestational age, receipt of antenatal steroids, cesarean section delivery and singleton birth.Conclusion:Survival of ProLBW and ProSGA infants is uncommon, and survival without substantial morbidity is rare. Survival is positively associated with receipt of antenatal steroids and cesarean delivery.Journal of Perinatology advance online publication, 15 January 2015; doi:10.1038/jp.2014.233.

View details for DOI 10.1038/jp.2014.233

View details for PubMedID 25590218

Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study PEDIATRICS Lee, H. C., Powers, R. J., Bennett, M. V., Finer, N. N., Halamek, L. P., Nisbet, C., Crockett, M., Chance, K., Blackney, D., von Koehler, C., Kurtin, P., Sharek, P. J. 2014; 134 (5): E1378-E1386


There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects.This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support.There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%).Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices.

View details for DOI 10.1542/peds.2014-0863

View details for Web of Science ID 000344385900014

Hypothermia Therapy for Neonatal Hypoxic Ischemic Encephalopathy inthe State of California. journal of pediatrics Kracer, B., Hintz, S. R., Van Meurs, K. P., Lee, H. C. 2014; 165 (2): 267-273


To characterize the implementation of hypothermia for neonatal hypoxic ischemic encephalopathy (HIE) in a population-based cohort.Using the California Perinatal Quality Care Collaborative and California Perinatal Transport System linked 2010-2012 datasets, we categorized infants 36weeks' gestation with HIE as receiving hypothermia or normothermia. Sociodemographic and clinical factors were compared, and multivariable logistic regression was used to determine factors associated with hypothermia therapy.There were 238 reported encephalopathy cases in 2010, 280 in 2011, and 311 in 2012. Hypothermia therapy use in newborns with HIE increased from 59% to 73% across the study period, mainly occurring in newborns with mild or moderate encephalopathy. A total of 36 centers provided hypothermia and cared for 94% of infants, with the remaining 6% being cared for at one of 25 other centers. Of the centers providing hypothermia, 12 centers performed hypothermia therapy to more than 20 patients during the 3-year study period, and 24 centers cared for <20 patients receiving hypothermia. In-hospital mortality was 13%, which primarily was associated with the severity of encephalopathy.Our findings highlight an opportunity to explore practice-site variation and to develop quality improvement interventions to assure consistent evidence-based care of term infants with HIE and appropriate application of hypothermia therapy for eligible newborns.

View details for DOI 10.1016/j.jpeds.2014.04.052

View details for PubMedID 24929331

View details for PubMedCentralID PMC4111956

Caesarean delivery for twin gestation at 32-38 weeks does not lead to improved clinical outcomes for neonates or mothers. Evidence-based medicine Lee, H. C., Blumenfeld, Y. J. 2014; 19 (3): 119-?

View details for DOI 10.1136/eb-2013-101655

View details for PubMedID 24361755

Emergency Department Visits in the Neonatal Period in the United States PEDIATRIC EMERGENCY CARE Lee, H. C., Bardach, N. S., Maselli, J. H., Gonzales, R. 2014; 30 (5): 315-318


This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

View details for DOI 10.1097/PEC.0000000000000120

View details for Web of Science ID 000335749100004

View details for PubMedID 24759490

On-time scheduled cesarean delivery start time process-improvement initiative. Obstetrics and gynecology Blumenfeld, Y. J., Riley, E., Hilton, G., Lee, H. C., El-Sayed, Y. Y., Druzin, M. L. 2014; 123: 138S-9S


Cesarean deliveries comprise approximately 30% of all births, many of which are scheduled. Given the labile nature of labor and delivery units, scheduled cesarean deliveries are often delayed. Our aim was to improve on-time scheduled cesarean delivery start times.A multidisciplinary team (obstetrician-gynecologist, nursing, anesthesia, and hospital administration) met to review scheduled cesarean delivery data, identify logistic barriers to on-time starts, and develop a plan to improve cesarean delivery start times. After identifying possible barriers to on-time starts, the following process was instituted: planned preoperative visit 1-2 days before scheduled cesarean delivery, mandatory submission of History & Physical and consent forms by the time of the preoperative visit, and initial preparation of the first scheduled patient for cesaren delivery by nighttime nursing before morning change of shift. The process launched on March 1, 2013. Data from scheduled cesarean deliveries 6 months before and 3 months after the initiative were reviewed and analyzed.Of 1,298 total cesarean deliveries, 423 were scheduled, defined as cesarean delivery scheduled at least 24 hours in advance (300 before and 123 after the initiative). Sixty-four of 300 scheduled cesarean deliveries (21.3%) were on time before compared with 67 of 123 (54.5%) after the initiative began (P<.001). Among delayed cases, there was no difference in the average delay time between those before and after the initiative (55.7 compared with 54.4 minutes P=.93); however, 50.7% of cases were either on time or delayed by 15 minutes or less before the initiative compared with 69.9% of cases after (P<.001).A multidisciplinary initiative significantly increased scheduled cesarean delivery on-time start times.

View details for DOI 10.1097/01.AOG.0000447113.07157.f3

View details for PubMedID 24770007

Urine culture results and adverse outcomes in women with pyelonephritis. Obstetrics and gynecology Berger, V. K., Yeaton-Massey, A., Kassis, J., Blumenfeld, Y. J., Lee, H. C., Druzin, M. 2014; 123: 138S-?


A retrospective cohort study of patients with pyelonephritis in pregnancy and immediately postpartum was conducted. Participants delivered between 2005 and 2009 at a single university center (Lucile Packard Children's Hospital at Stanford) were reviewed. Pyelonephritis was defined by a temperature greater than 38.0C, flank pain or costovertebral angle tenderness, and bacteruria or pyuria on urinalysis. All patients with pyelonephritis and urine culture results were included. Univariate analyses were performed with the test. Means were compared with the Student's t test.One hundred thirteen patients were admitted with pyelonephritis and had a urine culture performed. Of the entire cohort, 70% of patients were Hispanic, 53% were nulliparous, and most were diagnosed in the third trimester. A total of 94 patients (83%) had positive urine cultures. There were no differences in adverse outcomes (preterm birth, anemia, bacteremia, acute respiratory distress syndrome, and hospital stay) between those with positive and negative urine cultures. Among those with positive cultures, there was a statistically significant increase in preterm birth (less than 37 weeks of gestation) between those with resistant uropathogens and those with pan-sensitive pathogens (26.5% compared with 7.6%, P=.01) ().(Table is included in full-text article.): Among women with pyelonephritis, complications did not differ between those with positive and negative urine culture results. Women with resistant bacterial uropathogens are at increased risk for preterm birth compared with those with sensitive pathogens.

View details for DOI 10.1097/01.AOG.0000447112.69038.68

View details for PubMedID 24770006

The impact of an intervention package promoting effective neonatal resuscitation training in rural China. Resuscitation Xu, T., Wang, H., Gong, L., Ye, H., Yu, R., Wang, D., Wang, L., Feng, Q., Lee, H. C., McGowan, J. E., Zhang, T. 2014; 85 (2): 253-259


To evaluate an intervention package promoting effective neonatal resuscitation training at county level hospitals across China.The intervention package was implemented across 4 counties and included expert seminars, training workshops, establishment of hospital-based resuscitation teams, and supervision of training by national and provincial instructors. Upon completing the activities, a survey was conducted in all county hospitals in the 4 intervention counties and 4 randomly selected control counties. Data on healthcare providers' knowledge and self-confidence, and incidence of deaths from birth asphyxia from 2009 to 2011 in all hospitals were collected and compared between the two groups.Eleven intervention and eleven control hospitals participated in the evaluation, with 97 and 87 health providers, respectively, completing the questionnaire survey. Over 90% of intervention hospitals had implemented neonatal resuscitation related practice protocols, while in control hospitals the proportion was less than 55%. The average knowledge scores of health providers in the intervention and control counties taking a written exam were 9.21.2 and 8.41.5, respectively (P<0.001) out of maximum possible score of 10, and the average self-confidence scores were 57.32.5 and 54.18.2, respectively (P<0.001). Incidence of birth asphyxia (defined as 1-min Apgar score7) decreased from 8.8% to 6.0% (P<0.001) in the intervention counties, and asphyxia-related deaths in the delivery room decreased from 27.6 to 5.0 per 100,000 (P=0.076). There was no difference over time in asphyxia rates for the control counties.The intervention has not only improved skills of health providers, decreased the mortality and morbidity of birth asphyxia, but also resulted in effective implementation of guidelines and protocols within hospitals.

View details for DOI 10.1016/j.resuscitation.2013.10.020

View details for PubMedID 24176723

Oral misoprostol versus vaginal dinoprostone for labor induction in nulliparous women at term. Journal of perinatology Faucett, A. M., Daniels, K., Lee, H. C., El-Sayed, Y. Y., Blumenfeld, Y. J. 2014; 34 (2): 95-99


Objective:To compare the efficacy of oral misoprostol to vaginal dinoprostone for labor induction in nulliparous women.Study design:Admissions for labor induction from January 2008 to December 2010 were reviewed. Patients receiving oral misoprostol were compared with those receiving vaginal dinoprostone. The primary outcome was time from induction agent administration to vaginal delivery. Secondary outcomes included vaginal delivery within 24h, mode of delivery and maternal and fetal outcomes.Result:A total of 680 women were included: 483 (71%) received vaginal dinoprostone and 197 (29%) received oral misoprostol. Women who received oral misoprostol had a shorter interval to vaginal delivery (27.2 vs 21.9h, P<0.0001) and were more likely to deliver vaginally in <24h (47% vs 64%, P=0.001). There was no increase in the rate of cesarean delivery or adverse maternal or neonatal outcomes.Conclusion:Labor induction with oral misoprostol resulted in shorter time to vaginal delivery without increased adverse outcomes in nulliparous women.

View details for DOI 10.1038/jp.2013.133

View details for PubMedID 24157494

Incidence and Impact of CMV Infection in Very Low Birth Weight Infants. Pediatrics Turner, K. M., Lee, H. C., Boppana, S. B., Carlo, W. A., Randolph, D. A. 2014


Congenital cytomegalovirus (CMV) is the leading cause of nongenetic deafness in children in the United States and can cause neurodevelopmental impairment in term infants. Limited data exist regarding congenital CMV infections in preterm infants. We aimed to determine the incidence and association with outcomes of congenital CMV in very low birth weight (VLBW) preterm infants.VLBW infants born in 1993 to 2008 and admitted to the University of Alabama in Birmingham Regional Neonatal ICU were screened on admission for congenital CMV. CMV status and clinical outcomes were identified by using internal patient databases and hospital-based medical records. The primary outcome was death. Secondary outcomes included evidence of neurologic injury in the form of abnormal cranial ultrasound findings, sensorineural hearing loss, or abnormal motor development. Multivariate analysis was performed.Eighteen of 4594 VLBW infants had congenital CMV (0.39%; 95% confidence interval, 0.25%-0.62%). An additional 16 infants (0.35%; 95% confidence interval, 0.21%-0.57%) were identified who acquired CMV postnatally. Congenital CMV was not associated with death. Compared with controls, congenitally infected VLBW infants were more likely to have hearing loss at initial screening (67% vs 9%, P < .0001) and confirmed at follow-up (83% vs 2.1%, P < .0001). Congenital CMV was also associated with abnormal neuroimaging (72% vs 25%, P < .0001) and adverse developmental motor outcomes (43% vs 9%, P = .02). Acquired CMV was not associated with any adverse outcomes.Congenital CMV in VLBW infants is associated with high rates of neurologic injury and hearing loss but not death.

View details for DOI 10.1542/peds.2013-2217

View details for PubMedID 24488749

Maternal determinants of breast milk feeding in a level III neonatal intensive care unit Journal of Neonatal Nursing Martin-Anderson, S., Lee, H. C. 2014; 21 (4): 150-156
Outcomes of extremely preterm infants after delivery room cardiopulmonary resuscitation in a population-based cohort. Journal of perinatology : official journal of the California Perinatal Association Handley, S. C., Sun, Y., Wyckoff, M. H., Lee, H. C. 2014


Objective:To describe the relationship of delivery room cardiopulmonary resuscitation (DR-CPR) to short-term outcomes of extremely preterm infants.Study design:This was a cohort study of 22 to 27+6/7 weeks gestational age (GA) infants during 2005 to 2011. DR-CPR was defined as chest compressions and/or epinephrine administration. Multivariable logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) associated with DR-CPR; analysis was stratified by GA.Result:Of the 13758 infants, 856 (6.2%) received DR-CPR. Infants 22 to 23+6/7 weeks receiving DR-CPR had similar outcomes to non-recipients. Infants 24 to 25+6/7 weeks receiving DR-CPR had more severe intraventricular hemorrhage (OR 1.36, 95% CI 1.07, 1.72). Infants 26 to 27+6/7 weeks receiving DR-CPR were more likely to die (OR 1.81, 95% CI 1.30, 2.51) and have intraventricular hemorrhage (OR 2.10, 95% CI 1.56, 2.82). Adjusted hospital DR-CPR rates varied widely (median 5.7%).Conclusion:Premature infants receiving DR-CPR had worse outcomes. Mortality and morbidity varied by GA.Journal of Perinatology advance online publication, 18 December 2014; doi:10.1038/jp.2014.222.

View details for DOI 10.1038/jp.2014.222

View details for PubMedID 25521563

Evaluating and Improving the Safety and Quality of Neonatal Intensive Care Fanaroff and Martin's Neonatal-Perinatal Medicine Profit, J., Lee, H. C., Gould, J. B., Horbar, J. D. edited by Martin, R., Fanaroff, A., Walsh, M. Elsevier. 2014; 10: 5988
Consequences of the Affordable Care Act for Sick Newborns. Pediatrics Profit, J., Wise, P. H., Lee, H. C. 2014

View details for DOI 10.1542/peds.2014-0470

View details for PubMedID 25311609

Neurodevelopmental Outcomes for Infants Born With Congenital Heart Disease NeoReviews Chock, V., Lee, H. C. 2014; 15 (8): e344-53

View details for DOI 10.1542/neo.15-8-e344

Accounting for variation in length of NICU stay for extremely low birth weight infants. Journal of perinatology Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B. 2013; 33 (11): 872-876


Objective:To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.Study Design:We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.Results:There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).Conclusion:Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

View details for DOI 10.1038/jp.2013.92

View details for PubMedID 23949836

View details for PubMedCentralID PMC3815522

Measuring hospital quality using pediatric readmission and revisit rates. Pediatrics Bardach, N. S., Vittinghoff, E., Asteria-Pealoza, R., Edwards, J. D., Yazdany, J., Lee, H. C., Boscardin, W. J., Cabana, M. D., Dudley, R. A. 2013; 132 (3): 429-436


To assess variation among hospitals on pediatric readmission and revisit rates and to determine the number of high- and low-performing hospitals.In a retrospective analysis using the State Inpatient and Emergency Department Databases from the Healthcare Cost and Utilization Project with revisit linkages available, we identified pediatric (ages 1-20 years) visits with 1 of 7 common inpatient pediatric conditions (asthma, dehydration, pneumonia, appendicitis, skin infections, mood disorders, and epilepsy). For each condition, we calculated rates of all-cause readmissions and rates of revisits (readmission or presentation to the emergency department) within 30 and 60 days of discharge. We used mixed logistic models to estimate hospital-level risk-standardized 30-day revisit rates and to identify hospitals that had performance statistically different from the group mean.Thirty-day readmission rates were low (<10.0%) for all conditions. Thirty-day rates of revisit to the inpatient or emergency department setting ranged from 6.2% (appendicitis) to 11.0% (mood disorders). Study hospitals (n = 958) had low condition-specific visit volumes (37.0%-82.8% of hospitals had <25 visits). The only condition with >1% of hospitals labeled as different from the mean on 30-day risk-standardized revisit rates was mood disorders (4.2% of hospitals [n = 15], range of hospital performance 6.3%-15.9%).We found that when comparing hospitals' performances to the average, few hospitals that care for children are identified as high- or low-performers for revisits, even for common pediatric diagnoses, likely due to low hospital volumes. This limits the usefulness of condition-specific readmission or revisit measures in pediatric quality measurement.

View details for DOI 10.1542/peds.2012-3527

View details for PubMedID 23979094

View details for PubMedCentralID PMC3876751

Developing Physician-Scientists in the Fields of Neonatology and Pediatric Critical Care Medicine: An Effort to Formulate a Departmental Policy JOURNAL OF PEDIATRICS Oishi, P. E., Klein, O. D., Keller, R. L. 2013; 163 (3): 616-?

View details for DOI 10.1016/j.jpeds.2013.05.047

View details for Web of Science ID 000323985300001

View details for PubMedID 23973233

The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study PLOS ONE Acosta, C. D., Knight, M., Lee, H. C., Kurinczuk, J. J., Gould, J. B., Lyndon, A. 2013; 8 (7)


To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI=9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR=1.29; 35 years: aOR=1.41), had high-school education (aOR=1.63), public/no-insurance (aOR=1.22) or a cesarean section (primary: aOR=1.99; repeat: aOR=1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI=4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR=2.09), Asian (aOR=1.59), Hispanic (aOR=1.42), had public/no-insurance (aOR=1.52), delivered in hospitals with <1,000 births/year (aOR=1.93), were primiparous (aOR=2.03), had a multiple birth (aOR=3.5), diabetes (aOR=1.47), or chronic hypertension (aOR=8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR=3.72; aOR=4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI=17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI=40.8-74.4).The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

View details for DOI 10.1371/journal.pone.0067175

View details for Web of Science ID 000321341000034

View details for PubMedID 23843991

View details for PubMedCentralID PMC3699572

Perspectives on Promoting Breastmilk Feedings for Premature Infants During a Quality Improvement Project BREASTFEEDING MEDICINE Lee, H. C., Martin-Anderson, S., Lyndon, A., Dudley, R. A. 2013; 8 (2): 176-180


This study investigated clinicians' perspectives during a quality improvement project to promote breastmilk feedings in premature infants.From 2009 to 2010, 11 hospitals in the California Perinatal Quality Care Collaborative participated in a project to promote breastmilk feedings in premature infants. Audio recordings of monthly meetings held to encourage sharing of ideas were analyzed using qualitative methods to identify common themes related to barriers and solutions to breastmilk feeding promotion.Two broad categories were noted: communication and team composition. Communication subthemes included (1) communication among hospital staff, including consistent documentation, (2) communication with family, and (3) communication between transfer hospitals. Team composition subthemes included (4) importance of physician buy-in and (5) integrated teams designed to empower leaders.Optimizing communication among health professionals and parents and improving team composition may be key components of facilitating breastmilk feeding promotion in premature infants.

View details for DOI 10.1089/bfm.2012.0056

View details for Web of Science ID 000317472700007

View details for PubMedID 23186387

View details for PubMedCentralID PMC3616405

The accuracy of human senses in the detection of neonatal heart rate during standardized simulated resuscitation: implications for delivery of care, training and technology design. Resuscitation Chitkara, R., Rajani, A. K., Oehlert, J. W., Lee, H. C., Epi, M. S., Halamek, L. P. 2013; 84 (3): 369-372


Auscultation and palpation are recommended methods of determining heart rate (HR) during neonatal resuscitation. We hypothesized that: (a) detection of HR by auscultation or palpation will vary by more than 15BPM from actual HR; and (b) the inability to accurately determine HR will be associated with errors in management of the neonate during simulated resuscitation.Using a prospective, randomized, controlled study design, 64 subjects participated in three simulated neonatal resuscitation scenarios. Subjects were randomized to technique used to determine HR (auscultation or palpation) and scenario order. Subjects verbalized their numeric assessment of HR at the onset of the scenario and after any intervention. Accuracy of HR determination and errors in resuscitation were recorded. Errors were classified as errors of omission (lack of appropriate interventions) or errors of commission (inappropriate interventions). Cochran's Q and chi square test were used to compare HR detection by method and across scenarios.Errors in HR determination occurred in 26-48% of initial assessments and 26-52% of subsequent assessments overall. There were neither statistically significant differences in accuracy between the two techniques of HR assessment (auscultation vs palpation) nor across the three scenarios. Of the 90 errors in resuscitation, 43 (48%) occurred in association with errors in HR determination.Determination of heart rate via auscultation and palpation by experienced healthcare professionals in a neonatal patient simulator with standardized cues is not reliable. Inaccuracy in HR determination is associated with errors of omission and commission. More reliable methods for HR assessment during neonatal resuscitation are required.

View details for DOI 10.1016/j.resuscitation.2012.07.035

View details for PubMedID 22925993

Hospital-wide breastfeeding rates vs. breastmilk provision for very-low-birth-weight infants ACTA PAEDIATRICA Lee, H. C., Jegatheesan, P., Gould, J. B., Dudley, R. A. 2013; 102 (3): 268-272


To investigate the relationship between breastmilk feeding in very-low-birth-weight infants in the neonatal intensive care unit and breastmilk feeding rates for all newborns by hospital.This was a cross-sectional study of 111 California hospitals in 2007 and 2008. Correlation coefficients were calculated between overall hospital breastfeeding rates and breastmilk feeding rates of very-low-birth-weight infants. Hospitals were categorized in quartiles by crude and adjusted very-low-birth-weight infant rates to compare rankings between measures.Correlation between breastmilk feeding rates of very-low-birth-weight infants and overall breastfeeding rates varied by neonatal intensive care unit level of care from 0.13 for intermediate hospitals to 0.48 for regional hospitals. For hospitals categorized in the top quartile according to overall breastfeeding rate, only 46% were in the top quartile for both crude and adjusted very-low-birth-weight infant rates. On the other hand, when considering the lowest quartile for overall breastfeeding hospitals, three of 27 (11%) actually were performing in the top quartile of performance for very-low-birth-weight infant rates.Reporting hospital overall breastfeeding rates and neonatal intensive care unit breastmilk provision rates separately may give an incomplete picture of quality of care.

View details for DOI 10.1111/apa.12096

View details for Web of Science ID 000314656600022

View details for PubMedID 23174012

View details for PubMedCentralID PMC3566354

"Breastfeeding" by Feeding Expressed Mother's Milk PEDIATRIC CLINICS OF NORTH AMERICA Flaherman, V. J., Lee, H. C. 2013; 60 (1): 227-?


This article provides the pediatric community with a practical overview of milk expression and an update on the recent literature. Approaches for working mothers, preterm infants, critically ill infants, and mothers before lactogenesis II are presented separately, as these groups may benefit from practices tailored to individual needs.

View details for DOI 10.1016/j.pcl.2012.10.003

View details for Web of Science ID 000313137500012

View details for PubMedID 23178067

Comparing the utility of a novel neonatal resuscitation cart with a generic code cart using simulation: a randomised, controlled, crossover trial BMJ QUALITY & SAFETY Chitkara, R., Rajani, A. K., Lee, H. C., Hansen, S. F., Halamek, L. P. 2013; 22 (2): 124-129


To compare a novel neonatal resuscitation cart (NRC) to a generic code cart (GCC).A prospective, randomised, controlled, crossover trial was performed to compare the utility of the NRC with the GCC during simulated deliveries of extremely low birthweight infants and infants with gastroschisis. Fifteen subjects participated. Mean times and accuracy of equipment and supply retrieval were compared for each scenario using the Wilcoxon test.Mean acquisition times for the NRC were always faster (by 58% to 74%) regardless of scenario (p<0.01). Accuracy of equipment selection did not differ. Ease of use was judged using a Likert scale (1=easiest to use; 5=most difficult), with mean score for NRC 1.1 and GCC 3.7 (p<0.0001). All subjects rated the NRC as easier to use.The NRC was superior to the GCC in acquisition speed, supply selection and ease of use.

View details for DOI 10.1136/bmjqs-2012-001336

View details for Web of Science ID 000314211900005

View details for PubMedID 23112286

A Quality Improvement Project to Increase Breast Milk Use in Very Low Birth Weight Infants PEDIATRICS Lee, H. C., Kurtin, P. S., Wight, N. E., Chance, K., Cucinotta-Fobes, T., Hanson-Timpson, T. A., Nisbet, C. C., Rhine, W. D., Risingsun, K., Wood, M., Danielsen, B. H., Sharek, P. J. 2012; 130 (6): E1679-E1687


To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants.Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population.The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group.Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

View details for DOI 10.1542/peds.2012-0547

View details for Web of Science ID 000314802000033

View details for PubMedID 23129071

View details for PubMedCentralID PMC3507251

Utilization of available prenatal screening and diagnosis: effects of the California screen program JOURNAL OF PERINATOLOGY Blumenfeld, Y. J., Taylor, J., Lee, H. C., Hudgins, L., Sung, J. F., El-Sayed, Y. Y. 2012; 32 (12): 907-912


In 2009, the California Genetic Disease Branch introduced an aneuploidy screening program allowing Medi-Cal (state insured) patients access to state-sponsored first-trimester screening. The objective of this study was to assess the effect of greater access to prenatal screening on available resources at a single center.Data of prenatal screening and diagnostic procedures performed 4 months before the introduction of the program were compared with those of 12 months following the introduction.Between December 2008 and March 2010, 7689 women underwent first trimester screening, 1286 underwent amniocentesis and 398 underwent chorionic villus sampling. When a comparison was made between the 4 months before and the 12 months after the program's introduction, a greater number of nuchal translucency (NT) examinations was seen to have been performed (384 per month vs 513 per month, P=0.001). Prenatal diagnostic procedures did not increase, but a greater proportion was performed for positive screen results.Introduction of the California screening program was associated with increased NT procedures and fewer invasive procedures for advanced maternal age.

View details for DOI 10.1038/jp.2012.8

View details for Web of Science ID 000311831700002

View details for PubMedID 22402484

Maternal morbidity during childbirth hospitalization in California JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Lyndon, A., Lee, H. C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2012; 25 (12): 2529-2535


To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization.Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models.The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity.Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

View details for DOI 10.3109/14767058.2012.710280

View details for Web of Science ID 000311678300011

View details for PubMedID 22779781

View details for PubMedCentralID PMC3642201

Factors Associated with Failure to Screen Newborns for Retinopathy of Prematurity JOURNAL OF PEDIATRICS Bain, L. C., Dudley, R. A., Gould, J. B., Lee, H. C. 2012; 161 (5): 819-823


To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed.We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening.Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings.Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population.

View details for DOI 10.1016/j.jpeds.2012.04.020

View details for Web of Science ID 000310370600013

View details for PubMedID 22632876

View details for PubMedCentralID PMC3470784

Intestinal malrotation and catastrophic volvulus in infancy. journal of emergency medicine Lee, H. C., Pickard, S. S., Sridhar, S., Dutta, S. 2012; 43 (1): e49-51


Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.We performed a 7-year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.Although most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients' symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.

View details for DOI 10.1016/j.jemermed.2011.06.135

View details for PubMedID 22325550

View details for PubMedCentralID PMC3351570

Clinician Perspectives on Barriers to and Opportunities for Skin-to-Skin Contact for Premature Infants in Neonatal Intensive Care Units BREASTFEEDING MEDICINE Lee, H. C., Martin-Anderson, S., Dudley, R. A. 2012; 7 (2): 79-84


Our objective was to investigate key factors in promoting skin-to-skin contact (STSC) in the neonatal intensive care unit (NICU).As part of a California Perinatal Quality Care Collaborative on improving nutrition and promoting breastmilk feeding of premature infants, a multidisciplinary group of representatives from 11 hospitals discussed the progress and barriers in pursuing the project. A key component of the collaborative project was promotion of STSC. Sessions were audio-recorded, transcribed, and assessed using qualitative research methods with the aid of Atlas Ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Two primary investigators studied the transcripts for themes related to STSC. Using an iterative approach, selected themes were explored, and representative quotes were selected.Barriers to promoting STSC fell into broad themes of implementation, institutional, and familial factors. The main challenge identified in implementation was defining a clinically stable eligible population of patients. Key institutional factors were education and motivation of staff. Familial factors involved facilitation and sustained motivation of mothers. In response to these barriers, opportunities for promoting STSC were enacted or suggested by the group, including defining clinical stability for eligibility, facilitating documentation, strategies to increase parent and staff education and motivation, and encouraging maternal visitation and comfort.Our findings may be useful for institutions seeking to develop policies and strategies to increase STSC and breastmilk feeding in their NICUs.

View details for DOI 10.1089/bfm.2011.0004

View details for Web of Science ID 000302777000003

View details for PubMedID 22011130

View details for PubMedCentralID PMC3317520

Trends in Cesarean Delivery for Twin Births in the United States: 1995-2008 Reply OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B., Boscardin, W. J., El-Sayed, Y. Y., Blumenfeld, Y. J. 2012; 119 (3): 658-659
Trends in Cesarean Delivery for Twin Births in the United States 1995-2008 OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B., Boscardin, W. J., El-Sayed, Y. Y., Blumenfeld, Y. J. 2011; 118 (5): 1095-1101


To estimate trends and risk factors for cesarean delivery for twins in the United States.This was a cross-sectional study in which we calculated cesarean delivery rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean delivery rates by year and for vertex compared with breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.Cesarean delivery rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5%-92.1%) and the vertex twin category (45.1%-68.2%). The relative increase in the cesarean delivery rate for preterm and term neonates was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04-1.05).Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.

View details for DOI 10.1097/AOG.0b013e3182318651

View details for Web of Science ID 000296292600018

View details for PubMedID 22015878

View details for PubMedCentralID PMC3202294

The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Lee, H. C., Chien, A. T., Bardach, N. S., Clay, T., Gould, J. B., Dudley, R. A. 2011; 165 (5): 429-434


To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings.Cross-sectional study based on risk-adjusted nosocomial infection rates.NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008.One hundred twenty-six California NICUs and 10 487 VLBW infants.Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years.Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the statistic.Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89.The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.

View details for Web of Science ID 000290113500009

View details for PubMedID 21536958

Hypothermia in very low birth weight infants: distribution, risk factors and outcomes JOURNAL OF PERINATOLOGY Miller, S. S., Lee, H. C., Gould, J. B. 2011; 31: S49-S56


The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria.A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression.In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death.Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

View details for DOI 10.1038/jp.2010.177

View details for Web of Science ID 000289236900008

View details for PubMedID 21448204

Improved outcomes with a standardized feeding protocol for very low birth weight infants JOURNAL OF PERINATOLOGY McCallie, K. R., Lee, H. C., Mayer, O., Cohen, R. S., Hintz, S. R., Rhine, W. D. 2011; 31: S61-S67


The objective of this study was to evaluate the impact of a standardized enteral feeding protocol for very low birth weight (VLBW) infants on nutritional, clinical and growth outcomes.Retrospective analysis of VLBW cohorts 9 months before and after initiation of a standardized feeding protocol consisting of 6-8 days of trophic feedings, followed by an increase of 20ml/kg/day. The primary outcome was days to reach full enteral feeds defined as 160ml/kg/day. Secondary outcomes included rates of necrotizing enterocolitis and culture-proven sepsis, days of parenteral nutrition and growth end points.Data were analyzed on 147 VLBW infants who received enteral feedings, 83 before ('Before') and 64 subsequent to ('After') feeding protocol initiation. Extremely low birth weight (ELBW) infants in the After group attained enteral volumes of 120ml/kg/day (43.9 days Before vs 32.8 days After, P=0.02) and 160ml/kg/day (48.5 days Before vs 35.8 days After, P=0.02) significantly faster and received significantly fewer days of parenteral nutrition (46.2 days Before vs 31.3 days After, P=0.01). Necrotizing enterocolitis decreased in the After group among VLBW (15/83, 18% Before vs 2/64, 3% After, P=0.005) and ELBW infants (11/31, 35% Before vs 2/26, 8% After, P=0.01). Late-onset sepsis decreased significantly in the After group (26/83, 31% Before vs 6/64, 9% After, P=0.001). Excluding those with weight <3rd percentile at birth, the proportion with weight <3rd percentile at discharge decreased significantly after protocol initiation (35% Before vs 17% After, P=0.03).These data suggest that implementation of a standardized feeding protocol for VLBW infants results in earlier successful enteral feeding without increased rates of major morbidities.

View details for DOI 10.1038/jp.2010.185

View details for Web of Science ID 000289236900010

View details for PubMedID 21448207

Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality-Improvement Model PEDIATRICS Wirtschafter, D. D., Powers, R. J., Pettit, J. S., Lee, H. C., Boscardin, W. J., Subeh, M. A., Gould, J. B. 2011; 127 (3): 419-426


To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals.The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

View details for DOI 10.1542/peds.2010-1449

View details for Web of Science ID 000287845400043

View details for PubMedID 21339273

View details for PubMedCentralID PMC3387911

Antenatal Steroid Administration for Premature Neonates in California OBSTETRICS AND GYNECOLOGY Lee, H. C., Lyndon, A., Blumenfeld, Y. J., Dudley, R. A., Gould, J. B. 2011; 117 (3): 603-609


To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term.Clinical data for premature neonates born in 20052007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors.Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 20052007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999 2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001).A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

View details for DOI 10.1097/AOG.0b013e31820c3c9b

View details for Web of Science ID 000287649400013

View details for PubMedID 21446208

View details for PubMedCentralID PMC3072287

Translating evidence into practice, policy, and public health in perinatal medicine NeoReviews Lee, H. C., Dudley, R. A., Gonzales, R. 2011; 12 (8): e431-438

View details for DOI 10.1542/neo.12-8-e431

Breast-milk feeding of very low birth weight infants as a function of hospital demographics Journal of Perinatology Lee, H. C., Gould, J. B., Martin-Anderson, S., Dudley, R. A. 2011; 31 (Supplement): S82

View details for DOI 10.1038/jp.2010.179

Hematologic abnormalities and jaundice Rudolph's Pediatrics Lee, H. C., Madan, A. McGraw-Hill Medical Publishing Co.. 2011; 22nd ed.
Transition to Oral Feeding in Preterm Infants NeoReviews Sridhar, S., Arguello, S., Lee, H. C. 2011; 12 (8): e141-147

View details for DOI 10.1542/neo.12-3-e141

Low Apgar score and mortality in extremely preterm neonates born in the United States ACTA PAEDIATRICA Lee, H. C., Subeh, M., Gould, J. B. 2010; 99 (12): 1785-1789


To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates.Infant birth and death certificate data from the US National Center for Health Statistics for 2001-2002 were analysed. Primary outcome was 28-day mortality for 690, 933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and 5-min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age.Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks. Low Apgar score was associated with increased mortality in premature neonates, including those at 24-28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.

View details for DOI 10.1111/j.1651-2227.2010.01935.x

View details for Web of Science ID 000283690300010

View details for PubMedID 20626363

View details for PubMedCentralID PMC2970674

Prediction of Death for Extremely Premature Infants in a Population-Based Cohort PEDIATRICS Lee, H. C., Green, C., Hintz, S. R., Tyson, J. E., Parikh, N. A., Langer, J., Gould, J. B. 2010; 126 (3): E644-E650


Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

View details for DOI 10.1542/peds.2010-0097

View details for Web of Science ID 000281535700047

View details for PubMedID 20713479

Ultrasound estimation of fetal weight in small for gestational age pregnancies JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Blumenfeld, Y. J., Lee, H. C., Pullen, K. M., Wong, A. E., Pettit, K., Taslimi, M. M. 2010; 23 (8): 790-793


Approximately half of small for gestational age (SGA) cases are due to maternal or fetal pathology, and may result in significant neonatal morbidity and mortality. The estimated fetal weight (EFW) measurement is the cornerstone of ultrasonographic findings when diagnosing and managing SGA pregnancies. Our objective was to determine the ultrasound accuracy of EFW in SGA pregnancies.A retrospective chart review was performed of all pregnancies complicated by SGA from a single institution (Stanford University) over a 2-year-period (2004-2006). SGA was defined as EFW < or = 10%. 98 neonates whose last ultrasound for EFW occurred within 7 days of delivery were included in the study. The absolute differences between the EFW and birthweight (BW) were analyzed, and the absolute percent errors were calculated as (EFW - BW)/BW x 100. The mean absolute differences and mean absolute percent errors were analyzed across all gestational ages (GA) and EFWs using one-way analysis of variance.The mean absolute percent error for the entire cohort was 8.7% (+/-6.3%). There was no statistically significant difference in the mean absolute percent error across all GAs (<32 weeks, 32-36 weeks, >36 weeks), and EFWs (<1500 g, 1500-2000 g, >2000 g).Ultrasound measurement of EFW in SGA pregnancies is consistent across all GAs and EFW measurements.

View details for DOI 10.3109/14767050903387052

View details for Web of Science ID 000280592200006

View details for PubMedID 19968588

A National Survey of Pediatric Residents and Delivery Room Training Experience JOURNAL OF PEDIATRICS Lee, H. C., Chitkara, R., Halamek, L. P., Hintz, S. R. 2010; 157 (1): 158-U211


To investigate current delivery room training experience in US pediatric residency programs and the relationship between volume of delivery room training and confidence in neonatal resuscitation skills.Links to a web-based survey were sent to pediatric residency programs and distributed to residents. The survey concerned delivery room attendance during training and comfort level in leading neonatal resuscitation for various scenarios. Comfort level was rated on a 1 to 9 scale. Mixed models accounted for residency programs as random effects.For PL-3s, the mean number of deliveries attended was 60 (standard deviation, 43), ranging from 13 to 143 deliveries for individual residency programs. Residents' confidence level in leading neonatal resuscitation was higher when attending more deliveries, with 90.3% of those attending>48 deliveries having average score 5 or greater vs 51.5% of those attending<21 deliveries. Higher attendance also correlated with confidence in endotracheal intubation and umbilical line placement.Wide variability existed within and among residency programs in number of deliveries attended. Volume of experience correlated with confidence in leading neonatal resuscitation and related procedural skills.

View details for DOI 10.1016/j.jpeds.2010.01.029

View details for Web of Science ID 000278649200037

View details for PubMedID 20304418

View details for PubMedCentralID PMC2886184

Morbidity Risk at Birth for Asian Indian Small for Gestational Age Infants AMERICAN JOURNAL OF PUBLIC HEALTH Lee, H. C., Ramachandran, P., Madan, A. 2010; 100 (5): 820-822


Whether the traditional definition of small for gestational age (SGA) is an appropriate marker of risk for populations that have relatively lower birthweight is unclear. We determined proportions of White and Asian Indian SGA infants and those admitted to the special care nursery. Compared with White infants, Asian Indian infants were more likely to be SGA (14.5% versus 2.7%) and more likely to be admitted to the special care nursery (20.7% versus 3.7%), suggesting that traditional definitions of SGA may be applicable as a marker of risk.

View details for DOI 10.2105/AJPH.2009.165001

View details for Web of Science ID 000276828800015

View details for PubMedID 20299660

View details for PubMedCentralID PMC2853612

Factors Influencing Breast Milk versus Formula Feeding at Discharge for Very Low Birth Weight Infants in California JOURNAL OF PEDIATRICS Lee, H. C., Gould, J. B. 2009; 155 (5): 657-U94


To investigate incidence and factors influencing breast milk feeding at discharge for very low birth weight infants (VLBW) in a population-based cohort.We used data from the California Perinatal Quality Care Collaborative to calculate incidence of breast milk feeding at hospital discharge for 6790 VLBW infants born in 2005-2006. Multivariable logistic regression was used to examine which sociodemographic and medical factors were associated with breast milk feeding. The impact of removing risk adjustment for race was examined.At initial hospital discharge, 61.1% of VLBW infants were fed breast milk or breast milk supplemented with formula. Breast milk feeding was more common with higher birth weight and gestational age. After risk adjustment, multiple birth was associated with higher breast milk feeding. Factors associated with exclusive formula feeding were Hispanic ethnicity, African American race, and no prenatal care. Hospital risk-adjusted rates of breast milk feeding varied widely (range 19.7% to 100%) and differed when race was removed from adjustment.A substantial number of VLBW infants were not fed breast milk at discharge. Specific groups may benefit from targeted interventions to promote breast milk feeding. There may be benefit to reporting risk-adjusted rates both including and excluding race in adjustment when considering quality improvement initiatives.

View details for DOI 10.1016/j.jpeds.2009.04.064

View details for Web of Science ID 000271570900014

View details for PubMedID 19628218

Laparoscopy in women with unexplained infertility: a cost-effectiveness analysis FERTILITY AND STERILITY Moayeri, S. E., Lee, H. C., Lathi, R. B., Westphal, L. M., Milki, A. A., Garber, A. M. 2009; 92 (2): 471-480


To evaluate the cost effectiveness of laparoscopy for unexplained infertility.We performed a cost-effectiveness analysis using a computer-generated decision analysis tree. Data used to construct the mathematical model were extracted from the literature or obtained from our practice. We compared outcomes following four treatment strategies: [1] no treatment, [2] standard infertility treatment algorithm (SITA), [3] laparoscopy with expectant management (LSC/EM), and [4] laparoscopy with infertility therapy (LSC/IT). The incremental cost-effectiveness ratio (ICER) was calculated, and one-way sensitivity analyses assessed the impact of varying base-case estimates.Academic in vitro fertilization practice.Computer-simulated patients assigned to one of four treatments.Fertility treatment or laparoscopy.Incremental cost-effectiveness ratios.Using base-case assumptions, LSC/EM was preferred (ICER =$128,400 per live-birth in U.S. dollars). Changing the following did not alter results: rates and costs of multiple gestations, penalty for high-order multiples, infertility treatment costs, and endometriosis prevalence. Outcomes were most affected by patient dropout from infertility treatments-SITA was preferred when dropout was less than 9% per cycle. Less important factors included surgical costs, acceptability of twins, and the effects of untreated endometriosis on fecundity.Laparoscopy is cost effective in the initial management of young women with infertility, particularly when infertility treatment dropout rates exceed 9% per cycle.

View details for DOI 10.1016/j.fertnstert.2008.05.074

View details for Web of Science ID 000268915200011

View details for PubMedID 18722609

Changes in Attendance at Deliveries by Pediatric Residents 2000 to 2005 AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Rhee, C. J., Sectish, T. C., Hintz, S. R. 2009; 26 (2): 129-134


We sought to determine if pediatric resident attendance at deliveries for newborn assessment and resuscitation had changed over the years at a training hospital. Data were abstracted from medical records of newborns discharged during the same 6-week periods for 5 consecutive academic years spanning a period before and after resident duty hour regulation changes were implemented. Names of personnel attending deliveries were noted in delivery records. The proportions of deliveries attended by any practitioner were compared by year, as well as the proportion of deliveries attended by practitioner type and training level. A total of 2666 delivery records were reviewed. The proportions of deliveries attended by any practitioner over the 5 years were similar, ranging from 43 to 49%. The proportion of deliveries attended by pediatric residents was highest at 51 to 57% from 2000 to 2002, declined to a low of 5% during 2002 to 2003, and rose to 20 to 23% during 2003 to 2005 ( P < 0.0001). The decrease in attendance by residents was compensated by an increase in attendance by hospitalists. At this training institution, pediatric resident attendance at deliveries declined substantially over recent years, likely due in part to resident duty hour regulations and increased use of hospitalists in roles previously held by residents.

View details for DOI 10.1055/s-0028-1091395

View details for Web of Science ID 000262934700006

View details for PubMedID 18850515

A quality improvement project to improve admission temperatures in very low birth weight infants JOURNAL OF PERINATOLOGY Lee, H. C., Ho, Q. T., Rhine, W. D. 2008; 28 (11): 754-758


To review the results of a quality improvement (QI) project to improve admission temperatures of very low birth weight inborn infants.The neonatal intensive care unit at Lucile Packard Children's Hospital underwent a QI project to address hypothermic preterm newborns by staff education and implementing processes such as polyethylene wraps and chemical warming mattresses. We performed retrospective chart review of all inborn infants with birth weight <1500 g during the 18 months prior to (n=134) and 15 months after (n=170) the implementation period. Temperatures were compared between periods. Multivariable logistic regression was used to account for potential confounding variables. We compared mortality rates and grade 3 or 4 intraventricular hemorrhage rates between periods.The mean temperature rose from 35.4 to 36.2 degrees C (P<0.0001) after the QI project. The improvement was consistent and persisted over a 15-month period. After risk adjustment, the strongest predictor of hypothermia was being born in the period before implementation of the QI project (odds ratio 8.12, 95% confidence interval 4.63, 14.22). Although cesarean delivery was a strong risk factor for hypothermia prior to the project, it was no longer significant after the project. There was no significant difference in death or intraventricular hemorrhage detected between periods.There was a significant improvement in admission temperatures after a QI project, which persisted beyond the initial implementation period. Although there was no difference in mortality or intraventricular hemorrhage rates, we did not have sufficient power to detect small differences in these outcomes.

View details for DOI 10.1038/jp.2008.92

View details for Web of Science ID 000260795100005

View details for PubMedID 18580878

School outcomes of late preterm infants: Special needs and challenges for infants born at 32 to 36 weeks gestation JOURNAL OF PEDIATRICS Chyi, L. J., Lee, H. C., Hintz, S. R., Gould, J. B., Sutcliffe, T. L. 2008; 153 (1): 25-31


Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants.A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared.LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels.Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.

View details for DOI 10.1016/j.jpeds.2008.01.027

View details for Web of Science ID 000257154800010

View details for PubMedID 18571530

Ambiguous Genitalia in the Newborn NeoReviews Chi, C., Lee, H. C., Neely, E. K. 2008; 9 (2): e78-84

View details for DOI 10.1542/neo.9-2-e78

Oropharyngeal atresia in a preterm infant: A case report and review of the literature INTERNATIONAL JOURNAL OF PEDIATRIC OTORHINOLARYNGOLOGY Lee, H. C., O-Lee, T. J., Madan, A., Koltai, P. 2007; 71 (9): 1485-1489


Oropharyngeal atresia is a rare and often fatal condition that presents soon after birth with severe respiratory distress. We present a case of a premature infant who initially was suspected to have tracheo-esophageal atresia due to prenatal ultrasound findings of polyhydramnios and absent stomach bubble, but was found instead to have oropharyngeal atresia and a complete persistent buccopharyngeal membrane. This case is the first described in which the patient was successfully intubated through a small slit in the persistent membrane.

View details for DOI 10.1016/j.ijport.2007.05.026

View details for Web of Science ID 000249164000020

View details for PubMedID 17597231

Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine JOURNAL OF PERINATOLOGY Lee, H. C., Silverman, N., Hintz, S. R. 2007; 27 (5): 291-296


To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training.Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist.There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%).A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.

View details for DOI 10.1038/

View details for Web of Science ID 000246105400008

View details for PubMedID 17363908

Postnatal cytomegalovirus infection from frozen breast milk in preterm, low birth weight infants PEDIATRIC INFECTIOUS DISEASE JOURNAL Lee, H. C., Enright, A., Benitz, W. E., Madan, A. 2007; 26 (3): 276-276

View details for Web of Science ID 000245089900022

View details for PubMedID 17484235

Delivery mode by race for breech presentation in the US JOURNAL OF PERINATOLOGY Lee, H. C., El-Sayed, Y. Y., Gould, J. B. 2007; 27 (3): 147-153


To determine if there are differential cesarean delivery rates by race and other socio-demographic factors for women with breech infants.We calculated cesarean delivery rates for 186 727 White, African American, Hispanic and Asian women delivering breech singletons with gestational age 26 to 41 weeks born in 1999 and 2000 using data from the National Center for Health Statistics. Multivariable logistic regression was used to determine differences in mode of delivery by race, adjusting for socio-demographic and medical factors.Cesarean rates for breech were >80% in most gestational age groups. In 14 of 18 groups, Whites had higher cesarean delivery rates than African Americans. However, this finding did not persist after risk adjustment. Hispanics were more likely to deliver by cesarean delivery than African Americans and Whites.Breech singleton infants are predominantly born by cesarean delivery. Although African-American women with breech presentation have lower cesarean delivery rates than Whites, this difference is not present after adjusting for socio-demographic and medical factors. Hispanics were more likely to be delivered by cesarean delivery and this difference was amplified after risk adjustment. Asians had slightly lower cesarean rates after risk adjustment, but this varied widely according to Asian subgroup.

View details for DOI 10.1038/

View details for Web of Science ID 000244420900003

View details for PubMedID 17314983

Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status PEDIATRICS Lee, H. C., Gould, J. B. 2006; 118 (6): E1836-E1844


The goal was to characterize the relationship between cesarean section delivery and death for preterm vertex neonates according to intrauterine growth.Maternal and infant data from the National Center for Health Statistics for 1999 and 2000 were analyzed. Neonates with gestational ages of 26 to 36 weeks were characterized as small for gestational age (<10th percentile) or appropriate for gestational age (10th to 90th percentile). Mortality rates at 28 days and relative risks were calculated for each gestational age group according to mode of delivery.Cesarean section rates were higher for small-for-gestational-age neonates compared with appropriate-for-gestational-age neonates, most prominently from 26 weeks to 32 weeks of gestation, at which small-for-gestational-age neonates had cesarean section rates of 50% to 67%, whereas appropriate-for-gestational-age neonates had rates of 22% to 38%. Small-for-gestational-age neonates at gestational ages of <31 weeks had increased survival rates associated with cesarean section, whereas small-for-gestational-age neonates at >33 weeks and appropriate-for-gestational-age neonates overall had decreased survival rates associated with cesarean section. After adjustment for sociodemographic and medical factors, the survival advantage for small-for-gestational-age neonates at gestational ages of 26 to 30 weeks persisted.Cesarean section delivery was associated with survival for preterm small-for-gestational-age neonates but not preterm appropriate-for-gestational-age neonates. We speculate that vaginal delivery may be particularly stressful for small-for-gestational-age neonates. We found no evidence that prematurity alone is a valid indication for cesarean section for preterm appropriate-for-gestational-age neonates.

View details for DOI 10.1542/peds.2006-1327

View details for Web of Science ID 000242478900081

View details for PubMedID 17142505

Survival advantage associated with cesarean delivery in very low birth weight vertex neonates. Obstetrics and gynecology Lee, H. C., Gould, J. B. 2006; 107 (1): 97-105


To identify the indications for and any survival advantage associated with very low birth weight (VLBW) neonates delivered by cesarean.Maternal and infant data from the National Center for Health Statistics linked birth/death data set for 1999 to 2000 were analyzed. Maternal conditions associated with cesarean delivery were compared among birth weight groups for vertex neonates. Birth weight-specific 28-day mortality rates and relative risks were calculated with 95% confidence intervals. Multivariate logistic regression was performed to adjust for other factors that may be associated with survival.Cesarean delivery occurred frequently, more than 40% in most VLBW birth weight groups. Conditions associated with cesarean delivery in VLBW vertex neonates differed from those seen in non-VLBW vertex neonates. A survival advantage was associated with cesarean delivery in the birth weight analysis up to 1,300 g (P < .05). This decreased mortality for VLBW neonates delivered by cesarean persisted after adjusting for other factors associated with mortality.Very low birth weight vertex neonates are often born by cesarean delivery and have different maternal risk profiles from non-VLBW vertex neonates born by this route. Neonatal mortality was decreased in VLBW neonates delivered by cesarean. Further study is warranted to determine whether this may be a causal relationship or a marker of quality of care.II-2.

View details for PubMedID 16394046

Visual Diagnosis: A Newborn Who Has Everted Eyelids NeoReviews Lee HC 2004; 5 (9): e390
Visual Diagnosis: Poor Feeding and Emesis in a 1-day-old Male NeoReviews Lee, H. C., Woolf, K. 2004; 5 (11): e498
Crosslinked hemoglobin inhibits endothelium-dependent relaxations in isolated canine arteries GENERAL PHARMACOLOGY-THE VASCULAR SYSTEM Katusic, Z. S., Lee, H. C., Clambey, E. T. 1996; 27 (2): 239-244


1. Several previous in vivo studies demonstrated that crosslinked hemoglobin is a potent vasoconstrictor capable of significantly increasing arterial blood pressure following systemic administration. The precise mechanisms underlying the vascular effects of crosslinked hemoglobin are not clear. The present study was designed to determine the effect of crosslinked hemoglobin on the endothelial L-arginine-nitric oxide biosynthesis pathway in isolated canine arteries. 2. Isolated femoral and renal arteries were suspended in organ chambers for isometric tension recordings. Endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187 were studied in the absence or in the presence of crosslinked hemoglobin or hemoglobin. A radioimmunoassay technique was used to determine levels of guanosine 3',5'-cyclic monophosphate (cyclic GMP) and adenosine 3',5'-cyclic monophosphate (cyclic AMP). 3. A nitric oxide synthase inhibitor L-NAME (10(-4)M) selectively inhibited endothelium-dependent relaxations to acetylcholine and calcium ionophore A23187. The inhibitory effect of L-NAME was reversed by L-arginine (3 x 10(-4)M). Crosslinked hemoglobin (10(-7), 10(-6) and 10(-5)M) inhibited endothelium-dependent relaxations to acetylcholine (10(-9)-10(-5)M) or A23187 (10(-9)-10(-6)M). In the same concentration range, purified bovine hemoglobin exerted a similar inhibitory effect on relaxations mediated by activation of endothelial cells. Crosslinked hemoglobin (10(-6)M) significantly reduced basal production of cyclic GMP, but did not affect production of cyclic AMP. Acetylcholine (10(-6)M) stimulated production of cyclic GMP. This effect of acetylcholine was abolished in the presence of crosslinked hemoglobin. 4. These studies demonstrate that crosslinked hemoglobin impairs endothelium-dependent relaxations in isolated large conduit arteries. This effect appears to be mediated by the chemical antagonism of crosslinked hemoglobin against nitric oxide released from the endothelium. Inhibition of the endothelial L-arginine-nitric oxide biosynthesis pathway, with subsequent decrease of cyclic GMP in smooth muscle, may help to explain vasoconstrictor and pressor effects of crosslinked hemoglobin.

View details for Web of Science ID A1996UD24400008

View details for PubMedID 8919636