title: Association of a quality improvement program with neonatal outcomes in extremely preterm infants: a prospective cohort study.
abstract: BACKGROUND
  We previously demonstrated improvement in bronchopulmonary dysplasia and nosocomial infection among preterm infants at 12 neonatal units using the Evidence-based Practice for Improving Quality (EPIQ). In the current study, we assessed the association of Canada-wide implementation of EPIQ with mortality and morbidity among preterm infants less than 29 weeks gestational age.
  
  
  METHODS
  This prospective cohort study included 6026 infants admitted to 25 Canadian units between 2008 and 2012 (baseline year, n = 1422; year 1, n = 1611; year 2, n = 1508; year 3, n = 1485). Following a 1-year baseline period and 6 months of training and planning, EPIQ was implemented over 3 years. Our primary outcome was a composite of neonatal mortality and any of bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis and nosocomial infection. We compared outcomes for baseline and year 3 using multivariable analyses.
  
  
  RESULTS
  In adjusted analyses comparing baseline with year 3, the composite outcome (70% v. 65%; adjusted odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51 to 0.79), severe retinopathy (17% v. 13%; OR 0.60, 95% CI 0.45 to 0.79), necrotizing enterocolitis (10% v. 8%; OR 0.73, 95% CI 0.52 to 0.98) and nosocomial infections (32% v. 24%; OR 0.63, 95% CI 0.48 to 0.82) were significantly reduced. The composite outcome was lower among infants born at 26 to 28 weeks gestation (62% v. 52%; OR 0.62, 95% CI 0.49 to 0.78) but not among infants born at less than 26 weeks gestational age (90% v. 88%; OR 0.73, 95% CI 0.44 to 1.20).
  
  
  CONCLUSIONS
  EPIQ methodology was generalizable within Canada and was associated with significantly lower likelihood of the composite outcome, severe retinopathy, necrotizing enterocolitis and nosocomial infections. Infants born at 26 to 28 weeks gestational age benefited the most.
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Shoo K
authors.initials: SK
authors.lastname: Lee
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man. pshah@mtsinai.on.ca.
authors.forename: Prakesh S
authors.initials: PS
authors.lastname: Shah
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Nalini
authors.initials: N
authors.lastname: Singhal
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Khalid
authors.initials: K
authors.lastname: Aziz
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Anne
authors.initials: A
authors.lastname: Synnes
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Douglas
authors.initials: D
authors.lastname: McMillan
authors.affiliation: Department of Paediatrics (Lee, Shah), University of Toronto, Toronto, Ont.; Department of Pediatrics (Singhal), University of Calgary, Calgary, Alta.; Department of Pediatrics (Aziz), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Synnes), University of British Columbia, Vancouver, BC; Department of Pediatrics (McMillan), Dalhousie University, Halifax, NS; Department of Pediatrics (Seshia), University of Manitoba, Winnipeg, Man.
authors.forename: Mary M
authors.initials: MM
authors.lastname: Seshia
mesh_terms: D005260:Female; D005865:Gestational Age; D006801:Humans; D007226:Infant Mortality; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000401:mortality / Q000628:therapy; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D015931:Intensive Care, Neonatal / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D058996:Quality Improvement / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data