A framework to address key issues of neonatal service configuration in England: the NeoNet multimethods study

Abstract

BackgroundThere is an inherent tension in neonatal services between the efficiency and specialised care that comes with centralisation and the provision of local services with associated ease of access and community benefits. This study builds on previous work in South West England to address these issues at a national scale.Objectives(1) To develop an analytical framework to address key issues of neonatal service configuration in England, (2) to investigate visualisation tools to facilitate the communication of findings to stakeholder groups and (3) to assess parental preferences in relation to service configuration alternatives.Main outcome measuresThe ability to meet nurse staffing guidelines, volumes of units, costs, mortality, number and distance of transfers, travel distances and travel times for parents.DesignDescriptive statistics, location analysis, mathematical modelling, discrete event simulation and economic analysis were used. Qualitative methods were used to interview policy-makers and parents. A parent advisory group supported the study.SettingNHS neonatal services across England.DataNeonatal care data were sourced from the National Neonatal Research Database. Information on neonatal units was drawn from the National Neonatal Audit Programme. Geographic and demographic data were sourced from the Office for National Statistics. Travel time data were retrieved via a geographic information system. Birth data were sourced from Hospital Episode Statistics. Parental cost data were collected via a survey.ResultsLocation analysis shows that to achieve 100% of births in units with ≥ 6000 births per year, the number of birth centres would need to be reduced from 161 to approximately 72, with more parents travelling > 30 minutes. The maximum number of neonatal intensive care units (NICUs) needed to achieve 100% of very low-birthweight infants attending high-volume units is 36 with existing NICUs, or 48 if NICUs are located wherever there is currently a neonatal unit of any level. Simulation modelling further demonstrated the workforce implications of different configurations. Mortality modelling shows that the birth of very preterm infants in high-volume hospitals reduces mortality (a conservative estimate of a 1.2-percentage-point lower risk) relative to these births in other hospitals. It is currently not possible to estimate the impact of mortality for infants transferred into NICUs. Cost modelling shows that the mean length of stay following a birth in a high-volume hospital is 9 days longer and the mean cost is £5715 more than for a birth in another neonatal unit. In addition, the incremental cost per neonatal life saved is £460,887, which is comparable to other similar life-saving interventions. The analysis of parent costs identified unpaid leave entitlement, food, travel, accommodation, baby care and parking as key factors. The qualitative study suggested that central concerns were the health of the baby and mother, communication by medical teams and support for families.LimitationsThe following factors could not be modelled because of a paucity of data – morbidity outcomes, the impact of transfers and the maternity/neonatal service interface.ConclusionsAn evidence-based framework was developed to inform the configuration of neonatal services and model system performance from the perspectives of both service providers and parents.Future workTo extend the modelling to encompass the interface between maternity and neonatal services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Asphyxiated Neonates Treated with Hypothermia: Birth Place Matters

“…26 Higher volume NICUs have lower mortality rates and improved outcomes for premature infants [27][28][29][30] and very low birth weight infants. 31,32 These differences in outcomes reflect the variability of care that may exist, despite the regionalization of health care resources. 33 However, these differences in outcomes according to the hospital level of care were not as evident for births at term.…”

How can consultant-led childbirth care at time of delivery be maximised? A modelling study

“…The project included public and patient involvement (PPI) input 3 in preparation of the study design, and then by three workgroups during the project. The aims of PPI were (1) To ensure that the modelling work and health economics we carried out took into account the needs and concerns of parents and families who use childbirth and neonatal services, and (2) To explore the best way to communicate our findings to parents and the public and to involve them in decision making about the design and configuration of childbirth and neonatal services.…”

“…We have previously described the use of a genetic algorithm to optimise the planning of the number and locations of birth and neonatal services. 3 We have extended that work to focus on birth centres, and have…”

“…We have previously described the use of a genetic algorithm to optimise the planning of the number and locations of birth and neonatal services. 3 We have extended that work to focus on birth centres, and have extended our methodology to allow for optimisation of more parameters, generation of more potential solutions, and the use of planning footprints.…”

Information technology infrastructure, quality improvement and research: the UK National Neonatal Research Database

“…The NNRD is also widely used for research studies. These include health services research (13)(14)(15)(16)(17), health economics (18) and epidemiological studies (19)(20)(21). The NNRD is used to provide clinical decision support analyses, for example in relation to gestational age specific mortality (22), length of stay (23), development of a gestational case definition for necrotising enterocolitis (24), care of preterm babies with Downs Syndrome (25) and comparative evaluation of preterm growth (26).…”