Disentangling the Effects of Risk Factors and Clinical Care on Subnational Variation in Early Neonatal Mortality in the United States 英文参考文献.docVIP

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Disentangling the Effects of Risk Factors and Clinical Care on Subnational Variation in Early Neonatal Mortality in the United States 英文参考文献.doc

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Disentangling the Effects of Risk Factors and Clinical Care on Subnational Variation in Early Neonatal Mortality in the United States 英文参考文献

DisentanglingtheEffectsofRiskFactorsandClinical CareonSubnationalVariationinEarlyNeonatal MortalityintheUnitedStates LahnD.Straney1,2*,StephenS.Lim1,ChristopherJ.L.Murray1 1The Institute for Health Metrics and Evaluation, The Department of Global Health, University of Washington, Seattle, Washington, United States of America, 2DepartmentofEpidemiologyandPreventativeMedicine,MonashUniversity,Melbourne,Victoria,Australia Abstract Objective: Between 1990 and 2010, the U.S ranking in neonatal mortality slipped from 29th to 45th among countries globally.Substantialsubnationalvariationinnewbornmortalityalsoexists.Ourobjectiveistomeasuretheextenttowhich trendsandsubnationalvariationinearlyneonatalmortalityreflectdifferencesintheprevalenceofriskfactors(gestational ageandbirthweight)comparedtodifferencesinclinicalcare. Methods:ObservationalstudyusinglinkedbirthanddeathdataforallbirthsintheUnitedStatesbetween1996and2006. Weexaminedhealthservicearea(HSA)levelvariationintheexpectedearlyneonatalmortalityrate,basedongestational age (GA)andbirth-weight (BW), andGA-BWadjustedmortalityas aproxy forclinicalcare. Weanalyzed therelationship betweenselectedhealthsystemindicatorsandGA-BW-adjustedmortality. Results:Theearlyneonataldeath(ENND)ratedeclined12%between1996and2006(2.39to2.10per1000livebirths).This occurreddespiteincreasesinriskfactorprevalence.TherewassignificantHSA-levelvariationintheexpectedENNDrate (RateRatio:0.73–1.47)andtheGA-BWadjustedrate(Rateratio:0.63–1.68).Accountingforpretermvolume(definedas,34 weeks),thenumberofneonatologistandNICUbeds,25.2%and58.7%oftheHSA-levelvarianceinoutcomeswasexplained amongallbirthsandverylowbirthweightbabies,respectively. Conclusion: Improvements in mortality could be realized through the expansion or reallocation of clinical neonatal resources,particularlyinHSAswithahighvolumeofpretermbirths;however,preventionofpretermbirthsandlow-birth weightbabieshasagreaterpotentialtoimprovenewbornsurvivalintheUnitedStates. Citation:StraneyLD,LimSS