Assessing restructuration of perinatal care in Ile de France

1998-2009

C. Crenn Hebert, APHP, Colombes, Perinatal Network Hauts de Seine North, PERINAT-ARHIF, France

ORAH 2009

Create health information system at regional level

Dr C. Crenn Hebert, APHP, Perinatal Network Hauts de Seine North, FranceDr C. Menguy, Hal Montreuil Seine Saint-Denis, FranceE. Lebreton, « PERINAT-ARHIF » , Paris, FranceG. Echardour, ARHIF, Paris, FranceDr A. Serfaty APHP, Hal Trousseau, Perinatal Network Eastern Paris, FranceJ. Zeitlin INSERM, UMR S953, UPMC Univ Paris 06, France

Content

• Background: Ile de France region and policies• Method for creating information system:

– Health certificate– Hospital discharge summary

• Results: – Perinatal structures– Perinatal indicators– Focus on Hauts de Seine district

• Discussion

• Conclusion

Ile de France : > 1/5 French births

Background: perinatal policies Perinatal care: a priority

by Regional health authority

Objective: 80% very preterm births in level III perinatal centre (PC III)

Level I: maternity unit without neonatal care Level IIA: on-site neonatal care Level IIB: on-site neonatal intensive care unit Level III: on-site neonatal resuscitation Specialised PCIII: foetal medicine or neonatal surgery

*L'action collective périnatalité en Ile de France, 1996-2000, A. Serfaty, E. Papiernik, ed ENSP 2005

Regional Health Organization Schemes:

Assess and elaborate successive schemes (1994, 1999, 2006)

In partnership with the regional health authority and perinatal health clinicians

The need for data ….Regional birth commission Survey in 1998

1998: 8 Perinatal Centres level III+ 2 specialised PCIII (foetal medicine or neonatal surgery)

135 maternity units- unequal distribution of PCIII over the 8 districts

1998: Regional birth commission Survey:

only 60% of very preterm births in PC III

59%

40%

82%

52%

70%59%

64%

57%

Regionalisation of very preterm birth sites in the Paris region in 1998 ; Annie Serfaty et al. Santé publique 2003, vol 15, no 4, pp. 491-502

Creating information system: method

• Criteria:Use of existing databasesRoutine dataData are available quicklyData are validated

• Involving perinatal health professionals:>Analysis to be shared between regional health

authority and data producer

1- Health certificates• First one at birth (live birth): indicators of birth certificate (BC)

parental demographics, antenatal period, delivery, newborn characteristics (gestational age, birth weight…), first week events(followed by 2nd certificate at 9 months, 3rd certificate at 24 months)

• Sent to maternal and child protection services in district of parents residence

• Common regional database from all districts: in progress from 2002

Maternity unit, Neonatal unit

Birth certificates

MCPS of residence district(anonymous files)

Hospital

Health ministry

Data managementCommon regional data baseStatistics

ValidationModification

Analysis validated by regional medical group of MCPS Drs

HEALTH CERTIFICATES: Each livebirth (BC)

MATERNAL AND CHILD PROTECTION SERVICES: MCPSDistrict of residence

“Perinat-arhif” statisticianEpidemiological research unitRegional health authority

2- Hospital Discharge Data System : (French PMSI)

• Hospital Discharge Summary : perinatal indicators set in IDF region, for every hospital, depending of place of residence pregnant or mother stay newborn (live or stillborn > 2009) or neonate stay until 2008, no gestational age is notified

• But without any link Mother-Baby!

“PERINAT-ARHIF” system

Maternity unit, Neonatal unit

MID

HDDS UDS

Hospital Discharge SummaryLINKING FILE( anonymous files)

Hospital

e-PMSIHealth Ministery

Data managementPerinatal data baseStatistics

ValidationModification

Analysis validated by Perinatal health networks Medical committees

Quality ControlAudits

Hospital Discharge Data System : HDDSUnit Discharge Summary: UDS

Medical Information Department: MID

Hospital Discharge Summary+ Linking File: mother and baby+ direct validation process+ audits

=“PERINAT-ARHIF” system

“Perinat-arhif” teamRegional health authority

www.perinat-arhif.org

Download application programs 2006, 2007

Patient flows

But also:

- Regional summary tables

- Hospital summary tables …

85 perinatal indicators compatible:

. AUDIPOG (www.audipog.net)

. EUROPERISTAT (www.europeristat.com)

Completeness of the data

• Birth Certificates (BC)

2007

93.3%

• Hospital Discharge Summary (HDS)

2007

95.4%

Comparison with civil registration « INSEE »

Great heterogeneity between each district

But giving feed-back to professionals seems to improve the reliability

Completeness BC/district/ 2006 and 2007 / source INSEE civil registration

80,0%

85,0%

90,0%

95,0%

100,0%

% 2006 % 2007

Paris

Seine-et-Marne

Yvelines

Essonne

Hauts-de-Seine

Seine-saint-Denis

Val-de-Marne

Val d'Oise

Completeness HDS 2006 AND 2007 / INSEE

80,0%

85,0%

90,0%

95,0%

100,0%

% 2006 % 2007

Paris

Seine-et-Marne

Yvelines

Essonne

Hauts-de-Seine

Seine-saint-Denis

Val-de-Marne

Val d'Oise

Results

Perinatal structures

Perinatal indicators

Focus on Hauts-de-Seine district

Restructuring perinatal care in IDF

1998 170 000 births

by IDF residents : source civil registration INSEE

135 maternity units

8 PC III

2007 179 264 births

by IDF residents :(INSEE)

105 maternity units

14 PC III15 in 200816 in 2009

2007 – 14 PC III (incl spec PCIII)

Deliveries and perinatal centre type (source HDD)

PC I : decrease

PC II : stable

PC III: increase

34,2 33,1 30,8

24,8 23,925,2

19,719,5 19,6

21,4 23,5 24,4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006 2007 2008

Type I Type IIA Type IIB Type III

Newborns with birth weight <1500g (source HDD)

4,5 2,9 3,1

6,95,4 5,9

1211,6 12,7

76,680,1 78,3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2006 2007 2008

Type I Type IIA Type IIB Type III

2007 80% Newborns <1500g born in CP III (source HDD)

74%

83%

77%

81%

76%

87%

81%

83%

2007 78% Newborns <32 wk born in PC III (source BC)

72%

83%

75%

81%

73%

78%

80%

83%

0% to 2,8% gestational age missing

Focus on Hauts-de-Seine (HdS) district

Differences in populations between north and south of district (2007)

source HDD

Residents in North

• <1500g : 1,04%*

Residents in South

• <1500g : 0,77%*

* p= 0.03

Impact of not having a PC III? Differences in health care

Hauts de Seine North/ Hauts de Seine South (2007) (source HDD)

Residents in North

< 1500g born in PCIII: 74,4%*

Multiple delivery in PCIII:23,5%**

Residents in South

< 1500g born in PCIII: 91,3%*

Multiple delivery in PCIII 62,7%**

* p =0.003 **p<0.0001

2008 15th PC III in Hauts de Seine North

2008 Newborns <1500g born in PC III (source HDD)

81%

77%

77%

85%

72%

90%

84%

86%

Results of opening PC III in North 2008 Hauts de Seine North/ Hauts de Seine South (source HDD)

Residents in North

• < 1500g born in PCIII: 83,6% (ns)

• Multiple delivery in PCIII: 45,3%**

Residents in South 92

• < 1500g born in PCIII: 87,5% (ns)

• Multiple delivery in PCIII: 59,7%**

**p=0.001

Results of opening PC III in North 2008 Hauts de Seine North/ Hauts de Seine South (source HDD)

Residents in North 92

• < 1500g born in PC I or IIA: 7,0%

• Multiple delivery in PC I or IIA: 39,9%**

Residents in South 92

• < 1500g born in PC I or IIA: 8,0%

• Multiple delivery in PCI or IIA: 26,8%**

**p=0.002

Discussion

• Change in perinatal structures may be monitored at different levels

• Routine data information important for planning of maternity care

• Evolution in perinatal health indicators may also reflect:– Changes in health of the population – Changes in medical practices among health

professionals

Discussion

• Relevance of the initial indicator is questionable (rate of in-born very preterm birth)

• In Hauts de Seine district, previous PC level IIB is upgraded to PC level III

• Hospital discharge data provided only birth weight , but similar data are obtained from birth certificates with gestational age in 2007

Thoroughness and accuracy of the data:hard to achieve…

Conclusion

• Combining analysis from 2 routine information systems helps to provide validated data for a regional vision of restructuration

• Analysis at perinatal network level and smaller territorial scales is important to access population needs and the adequacy of health care provision.

Thank you for your attention

Any Questions?

1994-2009: Government policies in France

Change in organization of perinatal care– Level I: maternity unit without neonatal care

– Level IIA: on-site neonatal care

– Level IIB: on-site neonatal intensive care unit

– Level III: on-site neonatal resuscitation

Change in medical practice• Toward regionalisation: place of birth according to risk level• In utero-transport to avoid negative effect of post-natal

transport

2007 – 14 PC III27743

18624

19899

17932

Paris30820

24937

20331

18978

Living Births district volumes differ, PC III capacities also

922

923

Cli Sainte IsabelleHôp Américain

Hôp Max Fourestier Hôp BeaujonCli Lambert

Hôp Louis Mourier

CH Neuilly Courbevoie

IH Franco-Britannique

Cli Les Martinets

Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France

© 2008 ARHIF-APHP-CRAMIF tous droits réservés

Établissement AP-HP

Établissement Public de Santé

Établissement PSPH

Établissement Privé à but non lucratif

Établissement Privé à but lucratif

CPN III

CPN II B

CPN II A

CPN I

Réseau Périnatal 92 NordRéseau Périnatal 92 Nord

921

922

912

CMC Foch

CH des Quatre Villes (site Saint-Cloud)

CH des Quatre Villes (site Sèvres)

Hôp privé Antony

CHU Antoine Beclère

CH d' Orsay Cli de l' Yvette

Pôle de santé du Plateau (site Meudon)

Cli Ambroise Paré

Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France Réseaux de périnatalité d'Ile de FranceRéseaux de périnatalité d'Ile de France

© 2008 ARHIF-APHP-CRAMIF tous droits réservés

Établissement AP-HP

Établissement Public de Santé

Établissement PSPH

Établissement Privé à but non lucratif

Établissement Privé à but lucratif

Réseau Périnatal 92 SudRéseau Périnatal 92 Sud

CPN III

CPN II B

CPN II A

CPN I

Possibilité de collaboration avecRéseau Périnatal 92 Nord