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Complete Case Study #6: Outcome Oriented Perinatal Surveillance found in the Turnock text. Students must address the following:

· Using the health problem analysis framework, illustrate how infant (and specifically neonatal) mortality rates are affected by “better babies or better care.”

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· Describe the public health “science” underlying the Outcome Oriented Perinatal Surveillance System.

· Explain why the structure and process standards are not equal to quality care and better outcomes.

· Identify the aspects of perinatal networks and perinatal systems which influence the outcomes for referral hospitals. For community hospitals? Determine which level of hospitals likely merits the closest scrutiny.

· Determine which aspects of outcome-oriented regulatory systems place the regulators at risk and explain how.

· Which strategies are useful for gaining buy-in for new regulatory strategies?

· Determine if this case study reflect evidence-based public health and justify why or why not. If it does, classify which types of evidence (Evidence of what? Etiology/causation? Or effectiveness? Or adaptability of an intervention?) appear in this case study. Cite specific examples and explain how each fits into one of these categories.

· Assess which role, if any, do health disparities play in this case study?

CASE STUDY

Mike Mangan’s job with the city health department required travel via public transportation throughout the five boroughs that comprise New York City, exposing him to several interesting lessons. Most lack relevance to this story, but one important lesson was always to know where you are going and how you plan to get there. And even if you get off track and maybe even get lost, always keep the end in mind.

This keep-your-eyes-on-the-prize principle, however, frequently got in the way of doing the job young Dr. Mangan was traveling throughout New York City to do in the mid-

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970s. That job was to visit hospitals large and small to assess their compliance with the city’s licensing regulations for maternity and newborn care units. It is well recognized that New York City has a long and glorious history when it comes to maternity and newborn care, and the city health department took its responsibilities seriously. Each inspection team consisted of a physician, two public health nurses, and a public health social worker. Teams would spend a full day at most hospitals (2 to 3 days for the larger hospitals) meeting with administrators and professional staff, inspecting the physical facilities, reviewing policy and procedure manuals, talking to patients and their families, and examining countless patient records.

Each inspection would end with an exit conference that invariably included confrontational moments when the hospital staff would challenge the findings and/or dispute the recommendations of the review team. The most difficult interchanges often involved whether the licensing standards and regulations really equated with quality care and better outcomes. Although the inspection teams used state-of-the-art standards from the American College of Obstetricians and Gynecologists, American Academy of Pediatrics, and the National Committee on Perinatal Health, these confrontations virtually always arose.

Health department inspection teams commonly heard challenges such as these: So what if the bassinets in the nursery are 6 inches closer to one another than they should be, or if the only hand-washing sink in the room is not foot operated, or if the corridors are not as wide as the fire marshal required, or if two small nursery rooms have to share a registered nurse rather than each having one, or if the procedure manuals have not been updated in the past 3 years? Show me how these situations resulted in moms and babies dying—go check the records and see for yourselves! And Dr. Mangan and his team did, and found that outcomes were often much better than they feared and expected.

New York City was so well respected for the quality of its maternity and newborn care in the 1970s that delegations of public health and medical professionals would come from other parts of the United States or the world to see how it was done in the Big Apple. Dr. Mangan especially remembers one delegation as it was from his own hometown, Chicago. The Chicago health commissioner, director of maternal and child health (MCH), chairman of the city’s MCH advisory committee, and two topnotch neonatologists came as part of the Chicago delegation. Basically, they wanted to know why New York City’s outcomes for newborns were so much better than those of babies born in Chicago.

Dr. Mangan’s boss told him to look into the data for the two cities and the inspection reports his team had been conducting on maternity and newborn units in New York City to see if he could shed some light as to what New York City was doing right to make this happen. The New York City health department leaders wanted to be able to explain to their visiting counterparts why perinatal care in New York City was so much better than that in Chicago.

At the time (circa 1977), a few researchers were just beginning to advance a concept that characterizes the two main pathways for differences in neonatal outcomes in simple terms: “better babies or better care.” Did New York City have better outcomes because of better care (as the delegation from Chicago assumed), or were the differences actually due to better babies (a controversial topic even in those days)?

Long explanation made short, Dr. Mangan found that the birth weight distribution (i.e., the proportion of babies born in different birth weight categories) differed substantially between the two cities. Chicago had a much higher proportion of its babies born in the low birth weight (<2500 grams) and very low birth weight (<1500 grams, the very smallest) categories than did New York City. On the other hand, he found that, for babies in similar birth weight categories, outcomes were noticeably better for Chicago babies in virtually all weight categories. This finding suggested that perinatal care may actually have been better in Chicago than in New York City!

About 5 years and a few job changes later, Dr. Mangan found himself working back in his hometown for the Chicago Department of Health but with part of history repeating itself in terms of challenges and complaints advanced by hospital medical staff and administrators in Chicago. They argued that the city health department’s maternity and newborn inspections were too focused on things that did not matter for quality or outcomes. Through an extensive series of meetings with these medical professionals and hospital administrators, the Chicago Department of Health collaboratively examined the evidence and rationale supporting the existing regulations. This led the city health department to propose a strategy for licensing and regulating maternity and newborn units that would focus on outcomes instead of indicators ofstructure and process. The Outcome Oriented Perinatal Surveillance System (OOPSS) was the result.1 The approach in OOPSS was to use standardized mortality ratios, rather than crude death rates, as a tool to identify hospitals with outcomes that required additional investigation and to reduce the inspection burden (inspect less frequently, approve reasonable waiver requests for technical violations ofstructure and process standards) for those hospitals with more favorable outcomes. Incorporating outcome standards into perinatal regulations was a win-win proposition for both hospitals and health department inspection teams. Keeping the end in mind, in this case perinatal outcomes resonated with Mike Mangan based on his public health practice education in New York City.

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