title: Regional variation in antenatal corticosteroid use: a network-level quality improvement study.
abstract: OBJECTIVE
  Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions.
  
  
  METHODS
  We undertook cross-sectional analysis of 33,610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect.
  
  
  RESULTS
  From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance.
  
  
  CONCLUSIONS
  We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California; profit@stanford.edu.
authors.forename: J
authors.initials: J
authors.lastname: Profit
authors.affiliation: Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina; and.
authors.forename: B A
authors.initials: BA
authors.lastname: Goldstein
authors.affiliation: Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California.
authors.forename: J
authors.initials: J
authors.lastname: Tamaresis
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California;
authors.forename: P
authors.initials: P
authors.lastname: Kan
authors.affiliation: Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California; California Perinatal Quality Care Collaborative, Palo Alto, California;
authors.forename: H C
authors.initials: HC
authors.lastname: Lee
mesh_terms: D000305:Adrenal Cortex Hormones / Q000009:adverse effects / Q000627:therapeutic use*; D000328:Adult; D002140:California; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal; D008297:Male; D008423:Maternal Age; D011247:Pregnancy; D011297:Prenatal Exposure Delayed Effects; D011785:Quality Assurance, Health Care; D058996:Quality Improvement; D012041:Regional Medical Programs; D012127:Respiratory Distress Syndrome, Newborn / Q000517:prevention & control*; D012307:Risk Factors; D019371:Topography, Medical; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones
keywords: antenatal corticosteroids; neonatal intensive care; quality of care; variation