Prediction by maternal risk factors of neonatal intensive care admissions: evaluation of >59,000 women in national managed care programs.

OBJECTIVE: Managed care plans have adopted risk assessment tools as part of pregnancy disease state management strategies to assist in reducing poor pregnancy outcomes and related costs. We evaluated the relationships of maternal risk factors to determine which pregnancy risk factors were associated with neonatal intensive care unit (levels II and III) admission. STUDY DESIGN: Risk assessments were performed through perinatal telephone interviews of nurses with 59, 861 pregnant women during 1996 and 1997 calendar years as part of managed care maternity risk screening and education programs. A series of 3 interviews was conducted, at 17 weeks and 28 weeks average gestational age and at 2 weeks post partum. Univariate chi(2) analysis was performed on >50 historical and pregnancy risk factors to determine the associations with neonatal intensive care unit admission. Significant factors were included in a stepwise logistic regression model. Receiver operating curves were generated for the use of significant factors in a risk scoring system in the prediction of neonatal intensive care unit admission, and the percentages of neonatal intensive care unit days attributable to significant risk factors were calculated. RESULTS: Among the participants most women (90%) had their prenatal visit during the first trimester. The mean maternal age was 30.2 +/- 5.2 years, with 74% of women reportedly of white ethnicity, 86% married, and 44.3% primigravid. The mean gestational age at birth decreased with increasing number of fetuses from singletons to quadruplets. The chi(2) analysis identified 26 significant risk factors associated with neonatal intensive care unit admission. Of these, 14 remained significant by logistic regression. Multiple gestation, preterm premature rupture of membranes, diabetes, abruptio placentae, pregnancy-induced hypertension, and preterm labor were independently associated with at least a 3-fold risk of neonatal intensive care unit admission. A modeled risk scoring system that used these and other significant factors was poorly predictive of neonatal intensive care unit admission. However, an analysis of neonatal intensive care unit length of stay attributable to significant risk factors concluded that 19% of all neonatal intensive care unit days in this population were associated with multiple gestations. Furthermore, 85% of neonatal intensive care unit days were the result of infant lengths of stay >/=1 week. CONCLUSION: This analysis of a managed care population showed similar risk factors to those traditionally associated with neonatal intensive care unit admission. Although many of these risk factors are not preventable, identification of neonatal intensive care unit admission risks with a screening program may be of use for focusing interventions, and earlier identification of these factors may allow maximum impact of interventions. Importantly, a reduction in the incidence of higher-order multiple gestations might help to reduce neonatal intensive care unit admissions and costs.

Impact of the fetal fibronectin assay on admissions for preterm labor.

OBJECTIVE: The aim of the study was to determine whether use of the fetal fibronectin assay would decrease the number of admissions to labor and delivery for diagnosis and treatment of preterm labor. STUDY DESIGN: A prospective cohort design was used to compare preterm labor admissions during a 12-month period of fetal fibronectin assay use (study) against a baseline period before fetal fibronectin assay was implemented as standard protocol. Patients coming to the physician's office or hospital with signs and symptoms of preterm labor had a sample obtained for fetal fibronectin assay per labeling criteria. Comparisons were made with the Mann-Whitney U test, independent Student t test, chi2 test, and Fisher exact test. P <.05 was considered significant. RESULTS: There was no difference noted in the number of deliveries between the baseline and study years. During the study year 251 of 330 patients evaluated for preterm labor met study criteria and had the fetal fibronectin assay completed. Eight patients did not have fetal fibronectin assay results available because of specimen handling errors, leaving 243 subjects available for study. Compared with the baseline year, the study year had significantly fewer admissions for preterm labor, preterm labor admissions per patient, and prescriptions written for tocolytic agents. In addition, the length of stay per admitted patient was significantly reduced. The study population had no differences in neonatal outcomes from the baseline population in terms of deliveries at <35.0 weeks' gestation, number of admissions to the neonatal intensive care unit, neonatal intensive care unit length of stay, or days of ventilatory support per patient admitted to the neonatal intensive care unit. CONCLUSIONS: Use of the fetal fibronectin assay resulted in significantly reduced preterm labor admissions, length of stay, and prescriptions for tocolytic agents. No negative impact on neonatal outcomes was observed. Reductions in admissions for preterm labor and in charges per admission resulted in approximately $486,000 saved during the study period. A trend toward increased corticosteroid administration (for neonates ultimately admitted to the neonatal intensive care unit) was noted.