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Observational Study
. 2019 Oct 16:367:l5678.
doi: 10.1136/bmj.l5678.

Association of early postnatal transfer and birth outside a tertiary hospital with mortality and severe brain injury in extremely preterm infants: observational cohort study with propensity score matching

Kjell Helenius  1   2   3 , Nicholas Longford  3 , Liisa Lehtonen  1   2 , Neena Modi  3 , Chris Gale  4 ; Neonatal Data Analysis Unit and the United Kingdom Neonatal Collaborative
Affiliations
Observational Study

Association of early postnatal transfer and birth outside a tertiary hospital with mortality and severe brain injury in extremely preterm infants: observational cohort study with propensity score matching

Kjell Helenius et al. BMJ. .

Abstract

Objective: To determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes.

Design: Observational cohort study with propensity score matching.

Setting: National health service neonatal care in England; population data held in the National Neonatal Research Database.

Participants: Extremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio.

Main outcome measures: Death, severe brain injury, and survival without severe brain injury.

Results: 2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525).

Conclusions: In extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.

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Conflict of interest statement

Competing interests: All authors completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Flowchart of selection process of extremely preterm infants born less than 28 gestational weeks in England between 1 January 2008 and 31 December 2015. *74 infants born at less than 23 weeks without z score were matched based on sex, birth weight, and steroid use and were included in analyses. SCBU=special care baby unit; LNU=local neonatal unit
See this image and copyright information in PMC

Comment in

References

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