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The study reported by Kutschmann et al (1) shows that the mortality risk for very low birth weight infants is 34% higher in hospitals with less than 30 preterm infants < 1250 g birth weight per year compared to hospitals with higher patient volumes. Since the risk adjusted mortality in many small centers was below average, whereas it was above average in some larger centers, the authors conclude that the caseload is not a suitable indicator of the quality of care. According to the laws of stochastic processes, however, the wide variance of mortality in small centers may actually be the result of the small caseload per center. The lower mortality rate in some small hospitals over a time period of three years may thus be merely an effect of a lower caseload, not an argument against the regionalization of care for very premature infants, which makes sense for various other reasons too.

In spite of risk adjustment, mortality was systematically calculated to the disadvantage of perinatal centers.

Not including preterm infants admitted more than 24 hours after the birth or those referred to other units (17.5% of the cohort) seemingly leads to lower mortality rates in smaller centers (preterm infants that were transferred to larger centers mostly have severe complications) and a seeming increase in mortality in larger centers (since it is mostly healthy and stable babies that are referred to smaller centers from larger ones).

In adjusting the risk, parameters were considered that include poor basic care given to preterm infants (baseline deficit, maximum FiO2) as a risk-increasing factor. These variables reflect, however, the competence of the obstetric and neonatology team; including these into the risk adjustment blurs differences in the treatment quality of different centers.

Unfortunately, the differences in mortality were not stratified by gestational age, although the differences between large and small centers have been demonstrated to increase with falling gestational age (24). Such stratification might have provided some answers to the question of the gestational age threshold below which stronger regionalization of the care of preterm infants might be effective.

DOI: 10.3238/arztebl.2013.0116b

Dr. med. Norbert Teig, Abteilung für Neonatologie und pädiatrische
Intensivmedizin, Universitätskinderklinik und Perinatalzentrum Bochum
norbert.teig@ruhr-uni-bochum.de

Conflict of interest statement
The author declares that no conflict of interest exists.

1.
Kutschmann M, Bungard S, Kötting J, Trümner A, Fusch C, Veit C:
The care of preterm infants with birth weight below 1 250 g: risk-adjusted quality benchmarking as part of validating a caseload-based management system. Dtsch Arztebl Int 2012; 109(31–32): 519–26 VOLLTEXT
2.
Bartels DB, Wypij D, Wenzlaff P, Damann O, Poets CF: Hospital volume and neonatal mortality among very low birth weight infants. Pediatrics 2006; 117: 2206–14. CrossRef MEDLINE
3.
Teig N, Wolf HG, Bücker-Nott HJ: Mortalität bei Frühgeborenen < 32 Schwangerschaftswochen in Abhängigkeit von Versorgungsstufe und Patientenvolumen in Nordrhein-Westfalen. Z Geburtshilfe Neonatol 2007; 211: 118–22. CrossRef MEDLINE
4.
Trotter A, Pohlandt F: Aktuelle Ergebnisqualität der Versorgung von Frühgeborenen < 1 500 g Geburtsgewicht als Grundlage für eine Regionalisierung der Risikogeburten. Z Geburtshilfe Neonatol 2010; 214: 55–61. CrossRef MEDLINE
1.Kutschmann M, Bungard S, Kötting J, Trümner A, Fusch C, Veit C:
The care of preterm infants with birth weight below 1 250 g: risk-adjusted quality benchmarking as part of validating a caseload-based management system. Dtsch Arztebl Int 2012; 109(31–32): 519–26 VOLLTEXT
2.Bartels DB, Wypij D, Wenzlaff P, Damann O, Poets CF: Hospital volume and neonatal mortality among very low birth weight infants. Pediatrics 2006; 117: 2206–14. CrossRef MEDLINE
3.Teig N, Wolf HG, Bücker-Nott HJ: Mortalität bei Frühgeborenen < 32 Schwangerschaftswochen in Abhängigkeit von Versorgungsstufe und Patientenvolumen in Nordrhein-Westfalen. Z Geburtshilfe Neonatol 2007; 211: 118–22. CrossRef MEDLINE
4.Trotter A, Pohlandt F: Aktuelle Ergebnisqualität der Versorgung von Frühgeborenen < 1 500 g Geburtsgewicht als Grundlage für eine Regionalisierung der Risikogeburten. Z Geburtshilfe Neonatol 2010; 214: 55–61. CrossRef MEDLINE

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