Published onNeonatology Update
Q-and-A with Scott A. Lorch, MD, MSCE
Here, Scott Lorch, MD, MSCE, Director of the Clinical and Epidemiological Research at Children's Hospital of Philadelphia, discusses the innovative research group he leads, which is one of the largest neonatal/perinatal health services research groups in the country, as well as a few recent publications and presentations.
What is health services research and what should providers know about your findings?
Health services research is a broad field that examines how social, financial, organizational, policy and personal factors influence access to healthcare, the types and quality of care received, and ultimately the outcomes and costs of healthcare interventions. Neonatal health services and health policy research is unique because the dyad of mother and infant influence pregnancy and early infant outcomes. I lead a neonatal research group that has been funded continuously since 2004 to study a wide variety of topics focusing on the drivers of variation in outcomes of high-risk infants and mothers, answering the question, “Why, of these two newborns that have similar characteristics, did one of them experience a complication of preterm birth or a hospital readmission?” We have particular expertise in understanding the drivers of social and racial/ethnic disparities in health outcomes; assessing the quality of care received by infants; and understanding the importance of health policies and perinatal health systems on infant outcomes.
Can you describe some interesting insights your group has learned?
One insight pertains to racial segregation and intraventricular hemorrhage in preterm infants that was recently published in Pediatrics by Daria Murosko, MD, MPH, a first-year neonatology fellow at CHOP. She studied the impact of community segregation on a preterm infant’s risk of developing intraventricular hemorrhage (IVH), comparing this risk between non-Hispanic Black and non-Hispanic white infants. This comparison is important because of several publications showing that the risk of IVH is higher in non-Hispanic Black infants compared to other racial/ethnic groups. She found that mothers living in a highly segregated area were associated with a 20% increase in the odds that a non-Hispanic Black preterm infant would develop IVH, compared to no significant increase for non-Hispanic white preterm infants whose mother resided in such a highly segregated area. Such work provides needed information on how structural factors such as a mother’s living conditions may explain some of the observed racial/ethnic disparities in neonatal and pregnancy outcomes here in the United States.
How does a minority infant’s access to care, particularly high-quality care, both during their initial hospitalization and after discharge impact mortality and morbidity?
A publication last year by Gia Yannekis MD, a third-year resident at CHOP, found that preterm infants of minority racial/ethnic status experienced greater benefits from delivering at a hospital with a level 3 or 4 high-volume hospital compared to non-Hispanic white infants. This effect was most strongly seen in a reduction in the risk of common morbidities of preterm birth such as bronchopulmonary dysplasia (BPD) and intraventricular hemorrhage (IVH). A follow-up abstract published from this year’s Pediatric Academic Societies meeting found that this finding occurred because the lower-level hospitals that cared for minority patients had substantially worse quality than lower-level hospitals that cared for non-Hispanic white infants. Such work parallels data that was published by the Vermont Oxford Network that I was fortunate to be a co-author on, which showed similar gaps in the quality of neonatal care provided to non-Hispanic Black infants compared to other racial/ethnic groups.
What other barriers to accessing high-quality healthcare has your team found?
Barriers to accessing high-quality care are not limited to racial/ethnic minorities; we have shown that only 40% of preterm rural pregnancies deliver at a hospital with any sort of neonatal intensive care unit (NICU), with even lower levels when there is no local hospital nearby that has a NICU. Given the work we and others have done that demonstrates a 60%-300% improvement in mortality rates when preterm infants deliver at a hospital with the capability to care for the newborns immediately after delivery, such gaps in accessing high-quality care are an area for further investigation and intervention.
How is the CHOP Neonatology research team using this research to optimize outcomes?
Our group has a particular interest in developing and testing policies that may improve the outcome of high-risk mothers and infants. One example of such work is a recent publication by Diana Montoya-Williams, MD, examining the benefits of paid maternity leave. We have also explored the importance of maternal levels of care on infant and pregnancy outcomes, as well as further refinements of the neonatal levels of care work that I have previously published, that shows the importance of the number of infants with a gestational age < 32 weeks on optimizing their outcomes. This work, presented in June as part of the Pediatric Academic Societies summer neonatology webinar series, showed that mortality rates were optimized when NICUs cared for at least 40 infants, and morbidity rates were optimized when NICUs care for at least 100 infants. However, we do not know how these findings translate in settings, such as rural communities, that live far from a high-level NICU. Such research, though, is important to present in order to overcome barriers to developing evidence-based policies for infants and children.
These recent publications and presentations are just a snapshot of the population health approach that our group uses to understand the many barriers to achieving the best outcomes for preterm infants and their mothers. By understanding all of the factors — medical and non-medical — that influence outcomes, we can begin to develop interventions and policies to improve care. In this current medical and social climate, such research is critical to address the particular issues for an individual child.
Scott A. Lorch, MD, MSCE, is an attending neonatologist, Associate Chair of the Division of Neonatology and the Director of Clinical and Epidemiological Research, and Kristine Sandberg Knisely Professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania, with appointments in the Center for Clinical Epidemiology and Biostatistics, and a senior fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. Dr. Lorch received his Master of Science degree in Clinical Epidemiology (MSCE) from the Center for Clinical Epidemiology and Biostatistics at the University of Pennsylvania.
He currently is the principal investigator on the following three active federally funded projects:
- Effect of Changing NICU Patient Volumes and Levels of Care on Neonatal Outcomes, funded by the Agency for Healthcare Research and Quality (Grant Number R01HD084819)
- Predicting and Preventing Pediatric Hospital Readmissions, funded by the Agency for Healthcare Research and Quality (Grant Number R01 HS023538)
- HEAL Initiative: Antenatal Opioid Exposure Longitudinal Study Consortium (Outcomes of Babies with Opioid Exposure (OBOE) Study), Grant Number 1RL1HD104252/1PL1HD101059
- Obstetric Volume, Regionalization, and Maternal and Infant Outcomes