Association of Unexpected Newborn Deaths With Changes in Obstetric and Neonatal Process of Care

Abstract

IMPORTANCEThe death of a healthy term infant may signal patient safety and quality issues.Various initiatives aim to encourage clinicians to learn from these events, but little evidence exists regarding how exposure to an unexpected newborn death may alter clinician practice.OBJECTIVE To examine the association between an unexpected newborn death and changes in obstetric and newborn procedures that may be used in response to potential fetal distress or newborn complications. DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study used difference-in-differences analysis of 2011 to 2017 US vital statistics data from 477 US counties experiencing an unexpected newborn death during the study period. All in-hospital live births in the 477 counties during the study period were included. Data were analyzed from September 2019 to September 2020. EXPOSURESThe death of an infant aged 0 to 7 days following an unremarkable pregnancy owing to causes other than birth defects, accidents/assaults, or sudden infant death syndrome. MAIN OUTCOMES AND MEASURES Primary outcomes included binary variables capturingintervention in labor/delivery (induction, augmentation, cesarean delivery, forceps/vacuum) and procedures to avert and mitigate newborn complications (assisted ventilation, surfactant replacement therapy, antibiotics for suspected sepsis, neonatal intensive care unit admission). RESULTSThe main sample included 5.72 million births (2.54 million during preexposure time). Mean (SD) maternal age was 27.3 (5.8) years; 67% of mothers were White, and 12% were Black.Associations varied across the 4 estimated models. Following an unexpected newborn death, there was no significant increase in the probability of cesarean delivery in the full sample model (0.28 percentage points [pp]; 95% CI, −0.01 to 0.57 pp), but a significant increase in the other 3 models, with values ranging from 0.55 pp (95% CI, 0.21 to 0.88 pp) in the full sample model with matching to 0.66 pp (95% CI, 0.13 to 1.19 pp) in the 1-hospital county subsample with matching. There was a significant increase in the probability of newborn assisted ventilation in the full sample model with matching (0.46 pp; 95% CI, 0.08 to 0.83 pp), but no significant increase in the other 3 models, with estimates ranging from 0.33 pp (95% CI, −0.04 to 0.71 pp) to 0.69 pp (95% CI, −0.02 to 1.40 pp).An unexpected newborn death was not associated with a significant increase in antibiotic use in the full sample models (without matching: 0.19 pp; 95% CI, −0.00 to 0.39 pp; with matching: 0.22 pp; 95% CI: −0.02 to 0.46 pp), but was associated with a significant increase in both of the 1-hospital county subsample models (without matching: 0.38 pp; 95% CI, 0.02 to 0.73 pp; with matching: 0.39 pp; 95% CI, 0.01 to 0.77 pp). CONCLUSIONS AND RELEVANCEIn some study models, an unexpected newborn death was associated with statistically significant increases in subsequent use of procedures to avert and (continued) Key Points Question Was the occurrence of an unexpected newborn death associated with ch...

Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel

“…7 Breast and colorectal cancer diagnoses are common exposures across many PCPs’ careers, yet to our knowledge, have not been studied as potential adverse event exposures in context of physician decision-making. Prior related studies 34 , 35 , 36 , 37 have reported changes in physicians’ decisions in areas such as blood thinning medication prescriptions, cesarean deliveries, and pulmonary embolism testing. Another study 33 investigated colonoscopy-induced gastrointestinal bleeding and subsequent reductions in physicians’ colonoscopy orders.…”

“…Our observed magnitudes of change lie in a similar range as estimates in these studies and were sustained throughout the study period. 33 , 34 , 35 , 36 , 37 Additionally, this study contributes methodologically through its use of all-payer claims data to conduct longitudinal PCP-level analyses of practice pattern changes in relation to patient diagnoses and outcomes. This study is not limited to 1 specific health care system, but rather makes use of commercial and Medicaid claims for all primary care practices across 2 states.…”

“…Consistent with previous literature, we used the first new cancer diagnosis in the study period as the exposure of interest for PCPs with multiple new cancer diagnoses. 33 , 34 , 35 , 36 , 37 …”

“…We analyzed changes in screening rates over 4 quarters before and after a new cancer diagnosis. 33 , 35 , 36 , 37 Index patients whose new breast or colorectal cancer diagnoses were the study exposures were excluded from study outcomes to avoid a mechanical correlation between exposures and outcomes.…”

“… 28 , 29 , 30 , 31 For example, a 2018 randomized trial 32 of letters notifying physicians of opioid overdoses in patients to whom they prescribed opioids demonstrated a sharp decrease in prescribing. Additional studies 33 , 34 , 35 , 36 , 37 on adverse clinical events, such as gastrointestinal bleeding, pulmonary embolism diagnoses, and unexpected newborn deaths, have found associations between such events and downstream changes in physicians’ clinical decisions. It is plausible that a new cancer diagnosis could increase cancer screening rates through similar behavioral mechanisms.…”