From single-case analysis of neonatal deaths toward a further reduction of the neonatal mortality rate
-
André Sander
and
Roland Wauer
Abstract
Background
The infant mortality rate (IMR), a key indicator of the quality of a healthcare system, has remained at approximately 3.5‰ for the past 10 years in Germany. Generic quality indicators (QIs), as used in Germany since 2010, greatly help in ensuring such a good value but do not seem to be able to further reduce the IMR. The neonatal mortality rate (NMR) contributes to 65–70% of the IMR. We therefore propose single-case analysis of neonatal deaths as an additional method and show an efficient way to implement this approach.
Methods
We used the Nordic-Baltic classification (NBC) to detect avoidable neonatal deaths. We applied this classification to a sample of 1968 neonatal death records, which represent over 90% of all neonatal deaths in East Berlin from 1973 to 1989. All cases were analyzed as to their preventability based on the complete perinatal and clinical data by a special commission of different experts. The NBC was automatically applied through natural language processing and an ontology-based terminology server.
Results
The NBC was used to select the group of cases that had a high potential of avoidance. The selected group represented 6.0% of all cases, and 60.4% of the cases within that group were judged avoidable or conditionally avoidable. The automatic detection of malformations showed an F1 score of 0.94.
Conclusion
The results show that our method can be applied automatically and is a powerful and highly specific tool for selecting potentially avoidable neonatal deaths and thus for supporting efficient single-case analysis.
Acknowledgments
The authors thank the Friedrich Wingert Foundation for its permission to apply the terminology and ontology used here. The authors thank the company “ID Information und Dokumentation im Gesundheitswesen GmbH & Co KGaA” for its permission to work with their product ID LOGIK®. The authors are especially thankful to Prof. Dr. Dr. Inge Rapoport, nestor of German neonatology, who died in March 2017 at the age of 104 years, for providing the index cards.
Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
References
1. Wauer RR. Säuglings- und Kindersterblichkeit in Deutschland und Berlin. Unterschiede in Ost und West. In: Holzgreve A, Cossel GV, Hrsg. Geschichte der Berliner Krankenhäuser. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft; 2018. S. 97–128.Search in Google Scholar
2. Statistisches Bundesamt (Destatis), Genesis-Online; [cited 2017 Dec.]; Available from: https://www-genesis.destatis.de.Search in Google Scholar
3. Statistisches Bundesamt, Wiesbaden 2005, Bevölkerung und Erwerbstätigkeit, Gestorbene nach Alters- und Geburtsjahren - Fachserie 1 Reihe 1.S.3 - 1948-2003; [cited 2017 Dec.]; Available from: https://www.destatis.de/DE/Publikationen/Thematisch/Bevoelkerung/Bevoelkerungsbewegung/GestorbeneAltersundGeburtsjahre2010193039004.pdf.Search in Google Scholar
4. Borch-Christensen H, Langhoff-Roos J, Larsen S, Lindberg B, Wennergren M. The Nordic/Baltic perinatal death classification. Acta Obstet Gynecol Scand Suppl 1997;164:40–2.Search in Google Scholar
5. Knoema, Weltdatenatlas, [cited 2017 Dec.]; Available from: https://knoema.de/atlas/Japan/Infant-mortality-rate.Search in Google Scholar
6. Mohangoo AD, Blondel B, Gissler M, Velebil P, Macfarlane A, Zeitlin J, et al. International comparisons of fetal and neonatal mortality rates in high-income countries: should exclusion thresholds be based on birth weight or gestational age? PLoS One 2013;8:e64869.10.1371/journal.pone.0064869Search in Google Scholar PubMed PubMed Central
7. Deb-Rinker P, León JA, Gilbert NL, Rouleau J, Andersen AM, Bjarnadóttir RI, et al. Differences in perinatal and infant mortality in high-income countries: artifacts of birth registration or evidence of true differences? BMC Pediatr 2015;15:112.10.1186/s12887-015-0430-8Search in Google Scholar PubMed PubMed Central
8. Maternal and infant mortality, OECD Health Statistics 2017 Definitions, Sources and Methods, Jun 2017; [cited 2017 Dec.]; Available from: http://stats.oecd.org/wbos/fileview2.aspx?IDFile=9dc8f6ca-5c8d-4352-b81d-3baa28fdd000.Search in Google Scholar
9. MacDorman MF, Mathews TJ, Mohangoo AD, Zeitlin J. International comparisons of infant mortality and related factors: United States and Europe, 2010. National vital statistics reports; vol 63 no 5. Hyattsville, MD: National Center for Health Statistics; 2014.Search in Google Scholar
10. WHO Library Cataloguing-in-Publication. Data neonatal and perinatal mortality: country, regional and global estimates. Geneva: World Health Organization; 2006. ISBN 92 4 156320 6.Search in Google Scholar
11. Bührer C. Perinatalerhebung Berlin 2013. Geburtshilfe Frauenheilkd 2016;76:A4.10.1055/s-0036-1571401Search in Google Scholar
12. Hummler HD, Poets C. Mortalität sehr unreifer Frühgeborener – Erhebliche Diskrepanz zwischen Neonatalerhebung und amtlicher Geburten- /Sterbestatistik. Z Geburtsh Neonatol 2011;215:10–7.10.1055/s-0031-1271757Search in Google Scholar PubMed
13. AWMF online (2015); S1-Leitlinie 087-001: Empfehlungen für die strukturellen Voraussetzungen der perinatologischen Versorgung in Deutschland; [cited 2017 Dec.]; Available from: http://www.awmf.org/uploads/tx_szleitlinien/087-001l_S1_Perinatologische_Versorgung_2015-05.pdf.Search in Google Scholar
14. Neto MT. Perinatal care in Portugal: effects of 15 years of a regionalized system. Acta Paediatr 2006;95:1349–52.10.1080/08035250600615135Search in Google Scholar PubMed
15. Aoshima K, Kawaguchi H, Kawahara K. Neonatal mortality rate reduction by improving geographic accessibility to perinatal care centers in Japan. J Med Dent Sci 2011;58:29–40.Search in Google Scholar
16. Sudo A, Kuroda Y. The impact of centralization of obstetric care resources in Japan on the perinatal mortality rate. ISRN Obstet Gynecol. 2013, Article ID 709616, 5 pages. http://dx.doi.org/10.1155/2013/709616.10.1155/2013/709616Search in Google Scholar PubMed PubMed Central
17. Gmyrek D, Koch R, Vogtmann C, Kaiser A, Friedrich A. Warum Risikoadjustierung von Qualitätsmerkmalen?, demonstriert am Qualitätskriterium neonatale Spätinfektion. Sitzungsberichte der Leibniz-Sozietät der Wissenschaften zu Berlin 2013;115:85–94.Search in Google Scholar
18. Masson VL, Farquhar CM, Sadler LC. Validation of local review for the identification of contributory factors and potentially avoidable perinatal deaths. Aust N Z J Obstet Gynaecol 2016;56:282–8.10.1111/ajo.12454Search in Google Scholar PubMed
19. Merali HS, Lipsitz S, Hevelone N, Gawande AA, Lashoher A, Agrawal P, et al. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. BMC Pregnancy Childbirth 2014;14:280.10.1186/1471-2393-14-280Search in Google Scholar PubMed PubMed Central
20. Ministerium für Gesundheitswesen der DDR 1970, Richtlinie für die Tätigkeit der Fachkommissionen zur Senkung der Säuglings- und Kindersterblichkeit in den Bezirken und Kreisen. In: Ockel E. Gesundheitsschutz für Mutter und Kind. Beitrag zur Geschichte des Gesundheitswesens der Deutschen Demokratischen Republik [= Reihe Medizin und Gesellschaft, Bd. 2], hrsg. von der Interessengemeinschaft Medizin und Gesellschaft e.V., Berlin: trafo Verlagsgruppe, Berlin 1995.Search in Google Scholar
21. Grube E, Lorenz K. Gezielte Bekämpfung der Säuglingssterblichkeit durch Analyse des einzelnen Säuglingstodesfalles. Das Deutsche Gesundheitswesen 1958;45:1450–4.Search in Google Scholar
22. Aleman J, Brännström I, Liljestrand J, Pena R, Persson L, Steidingerl J. Saving more neonates in hospital: an intervention towards a sustainable reduction in neonatal mortality in a Nicaraguan hospital. Trop Doctor 1998;28:88–92.10.1177/004947559802800211Search in Google Scholar PubMed
23. Gaber E. Heft 52 - Sterblichkeit, Todesursachen und regionale Unterschiede. Berlin: Robert Koch-Institut; 2011.Search in Google Scholar
24. Langhoff-Roos J, Larsen S, Basys V, Lindmark G, Badokynote M. Potentially avoidable perinatal deaths in Denmark, Sweden and Lithuania as classified by the Nordic-Baltic classification. Br J Obstet Gyanecol 1998;105:1189–94.10.1111/j.1471-0528.1998.tb09973.xSearch in Google Scholar PubMed
25. DDR-Angaben vom Institut für Med. Statistik und Datenverarbeitung, Bereich I, Abt. Gesundheitsstatistik und Mitteilungen des Instituts für Sozialhygiene, 1989, private archive of the author RW.Search in Google Scholar
26. Wauer RR. Die Entwicklung der Neonatologie als Teil der Perinatologie an der Universitätsfrauenklinik der Charité in Berlin-Mitte. In: David M, Ebert AD, Hrsg. Geschichte der Berliner Universitäts-Frauenkliniken: Strukturen, Personen und Ereignisse in und außerhalb der Charité. Berlin: Walter de Gruyter GmbH & Co. KG; 2009, S. 88–130.10.1515/9783110223743.88Search in Google Scholar
27. Ingeborg Rapoport, [cited 2017 Dec.]; Available from: https://de.wikipedia.org/wiki/Ingeborg_Rapoport.Search in Google Scholar
28. Wingert F. SNOMED. Berlin: Springer-Verlag; 1984.10.1007/978-3-642-52119-5Search in Google Scholar
29. Wingert F. Automated indexing of SNOMED statements into ICD. Methods Inf Med 1987;26:93–8.10.1055/s-0038-1635494Search in Google Scholar
30. Medcalc©; [cited 2017 Dec.]; Available from: https://www.medcalc.org/calc/diagnostic_test.php.Search in Google Scholar
31. Cnattingius S, Norman M, Granath F, Petersson G, Stephansson O, Frisell T. Apgar Score components at 5 minutes: risks and prediction of neonatal mortality. Paediatr Perinat Epidemiol 2017;31:328–37.10.1111/ppe.12360Search in Google Scholar PubMed
32. Vogtmann C, Koch R, Gmyrek D, Kaiser A, Friedrich A. Risk-adjusted intraventricular hemorrhage rates in very premature infants – towards quality assurance between neonatal units. Dtsch Arztebl Int 2012;109:527–33.Search in Google Scholar
33. Harris BA, Wirtschafter DD, Huddleston JF, Perlis HW. In utero versus neonatal transportation of high-risk perinates: a comparison. Obstet Gynecol 1981;57:496–9.Search in Google Scholar
34. Broughton SJ, Berry A, Jacobe S, Cheeseman P, Tarnow-Mordi WO, Greenough A. The mortality index for neonatal transportation score: a new mortality prediction model for retrieved neonates. Pediatrics 2004;114:e424.10.1542/peds.2003-0960-LSearch in Google Scholar PubMed
35. Selbmann HK. Münchner Perinatalstudie 1975–77. Koeln-Loevenich: Deutscher Arzte-Verlag; 1980. ISBN-10: 3769180135.Search in Google Scholar
36. Bührer C. Perinatal- und Neonatalerhebung Berlin, [cited 2017 Dec.]; Available from: http://www.ggg-b.de/_download/unprotected/buehrer_c_perinatal_neonatalerhebung_berlin.pdf.Search in Google Scholar
37. Rüdiger M. Paradigmenwechsel in der Neonatologie. Sitzungsberichte der Leibniz-Sozietät der Wissenschaften zu Berlin 2013;115:95–110.Search in Google Scholar
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- Opinion Paper
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Articles in the same Issue
- Frontmatter
- Review
- Ductus venosus agenesis and fetal malformations: what can we expect? – a systematic review of the literature
- Opinion Paper
- Abnormally invasive placenta (AIP): pre-cesarean amnion drainage to facilitate exteriorization of the gravid uterus through a transverse skin incision
- Corner of Academy
- Midwife-assisted planned home birth: an essential component of improving the safety of childbirth in Sub-Saharan Africa
- Research Articles – Obstetrics
- Maternal body height is a stronger predictor of birth weight than ethnicity: analysis of birth weight percentile charts
- Chromosomal microarray findings in pregnancies with an isolated pelvic kidney
- Serum sFlt-1/PlGF ratio has better diagnostic ability in early- compared to late-onset pre-eclampsia
- A multidisciplinary approach to pregnancy loss: the pregnancy loss prevention center
- Relationship between intercellular adhesion molecule-1 and morbidly adherent placenta
- Birth risks according to maternal height and weight – an analysis of the German Perinatal Survey
- Research Articles – Fetus
- Untimely diagnosis of fetomaternal hemorrhage: what went wrong?
- Quantification of fetal myocardial function in pregnant women with diabetic diseases and in normal controls using speckle tracking echocardiography (STE)
- Prediction of postnatal developmental disabilities using the antenatal fetal neurodevelopmental test: KANET assessment
- Research Articles – Newborn
- Regional differences of hypothermia on oxidative stress following hypoxia-ischemia: a study of DHA and hypothermia on brain lipid peroxidation in newborn piglets
- Detection of cytomegalovirus in saliva from infants undergoing sepsis evaluation in the neonatal intensive care unit: the VIRIoN-C study
- Adverse neonatal outcomes and house prices in London
- A prospective analysis of intake and composition of mother’s own milk in preterm newborns less than 32 weeks’ gestational age
- Neonatal Ogg1/Mutyh knockout mice have altered inflammatory gene response compared to wildtype mice in the brain and lung after hypoxia-reoxygenation
- From single-case analysis of neonatal deaths toward a further reduction of the neonatal mortality rate
- Short Communication
- Comparison of two different treatments in depressed pregnant women: fetal growth characteristics and neonatal outcomes
