title: Use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population based cohort.
abstract: OBJECTIVE
  To evaluate the implementation of four high evidence practices for the care of very preterm infants to assess their use and impact in routine clinical practice and whether they constitute a driver for reducing mortality and neonatal morbidity.
  
  
  METHODS
  Prospective multinational population based observational study.
  
  
  METHODS
  19 regions from 11 European countries covering 850 000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project.
  
  
  METHODS
  7336 infants born between 24+0 and 31+6 weeks' gestation in 2011/12 without serious congenital anomalies and surviving to neonatal admission.
  
  
  METHODS
  Combined use of four evidence based practices for infants born before 28 weeks' gestation using an "all or none" approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; prevention of hypothermia (temperature on admission to neonatal unit ≥36°C); surfactant used within two hours of birth or early nasal continuous positive airway pressure. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge, and a composite measure of death or severe morbidity, or both. We modelled associations using risk ratios, with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital.
  
  
  RESULTS
  Only 58.3% (n=4275) of infants received all evidence based practices for which they were eligible. Infants with low gestational age, growth restriction, low Apgar scores, and who were born on the day of maternal admission to hospital were less likely to receive evidence based care. After adjustment, evidence based care was associated with lower in-hospital mortality (risk ratio 0.72, 95% confidence interval 0.60 to 0.87) and in-hospital mortality or severe morbidity, or both (0.82, 0.73 to 0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these interventions had been provided to all infants.
  
  
  CONCLUSIONS
  More comprehensive use of evidence based practices in perinatal medicine could result in considerable gains for very preterm infants, in terms of increased survival without severe morbidity.
authors.affiliation: INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France Jennifer.zeitlin@inserm.fr.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Zeitlin
authors.affiliation: Department of Health Sciences, University of Leicester, Leicester, UK.
authors.forename: Bradley N
authors.initials: BN
authors.lastname: Manktelow
authors.affiliation: INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France.
authors.forename: Aurelie
authors.initials: A
authors.lastname: Piedvache
authors.affiliation: Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, Rome, Italy.
authors.forename: Marina
authors.initials: M
authors.lastname: Cuttini
authors.affiliation: Department of Health Sciences, University of Leicester, Leicester, UK.
authors.forename: Elaine
authors.initials: E
authors.lastname: Boyle
authors.affiliation: Department of Neonatology, Radboud University Medical Centre, Nijmegen, Netherlands.
authors.forename: Arno
authors.initials: A
authors.lastname: van Heijst
authors.affiliation: Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland.
authors.forename: Janusz
authors.initials: J
authors.lastname: Gadzinowski
authors.affiliation: Department of Neonatology, Antwerp University Hospital, Antwerp; and Study Centre for Perinatal Epidemiology, Flanders, Brussels, Belgium.
authors.forename: Patrick
authors.initials: P
authors.lastname: Van Reempts
authors.affiliation: Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark.
authors.forename: Lene
authors.initials: L
authors.lastname: Huusom
authors.affiliation: Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark.
authors.forename: Tom
authors.initials: T
authors.lastname: Weber
authors.affiliation: Department of Obstetrics, University Hospital, Philipps University, Marburg, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Schmidt
authors.affiliation: EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal.
authors.forename: Henrique
authors.initials: H
authors.lastname: Barros
authors.affiliation: Health Department, Regione Lazio, Rome, Italy.
authors.forename: Dominico
authors.initials: D
authors.lastname: Dillalo
authors.affiliation: Unit of Neonates and Infants, Tallinn Children's Hospital, Tallinn, Estonia; and University of Tartu, Tartu, Estonia.
authors.forename: Liis
authors.initials: L
authors.lastname: Toome
authors.affiliation: Department of Clinical Science, Intervention and Technology, Division of Paediatrics, Karolinska Institute, Stockholm, Sweden; and Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Mikael
authors.initials: M
authors.lastname: Norman
authors.affiliation: INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Blondel
authors.affiliation: INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, 75014, France.
authors.forename: Mercedes
authors.initials: M
authors.lastname: Bonet
authors.affiliation: Department of Health Sciences, University of Leicester, Leicester, UK.
authors.forename: Elisabeth S
authors.initials: ES
authors.lastname: Draper
authors.affiliation: Children's Hospital, University Hospital, Philipps University, Marburg Germany.
authors.forename: Rolf F
authors.initials: RF
authors.lastname: Maier
mesh_terms: D005060:Europe / Q000453:epidemiology; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D062071:Infant, Extremely Premature; D007231:Infant, Newborn; D007235:Infant, Premature, Diseases / Q000401:mortality*; D011247:Pregnancy; D011446:Prospective Studies; D015996:Survival Rate