Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs

Maria L.V. Dizon, Rakesh Rao, Shannon E. Hamrick, Isabella Zaniletti, Robert Digeronimo, Girija Natarajan, Jeffrey R. Kaiser, John Flibotte, Kyong Soon Lee, Danielle Smith, Toby Yanowitz, Amit M. Mathur, An N. Massaro

Research output: Contribution to journalArticle

Abstract

Background: While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods: Children's Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks' gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results: Ninety-five percent (range: 83-100%) of patients with electrographic seizures, and 26% (0-81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was 89.90 (IQR 24.52,258.58). Conclusions: Amongst Children's Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.

Original languageEnglish (US)
Article number67
JournalBMC Pediatrics
Volume19
Issue number1
DOIs
StatePublished - Feb 27 2019

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Brain Hypoxia-Ischemia
Drug Utilization
Seizures
Induced Hypothermia
etiracetam
Pharmaceutical Preparations
Newborn Infant
Quality Improvement
Health Information Systems
Drug Costs
Valproic Acid
Phenytoin
Phenobarbital
Prescriptions
Databases
Pediatrics
Costs and Cost Analysis
Pregnancy
Population

All Science Journal Classification (ASJC) codes

  • Pediatrics, Perinatology, and Child Health

Cite this

Dizon, M. L. V., Rao, R., Hamrick, S. E., Zaniletti, I., Digeronimo, R., Natarajan, G., ... Massaro, A. N. (2019). Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. BMC Pediatrics, 19(1), [67]. https://doi.org/10.1186/s12887-019-1441-7
Dizon, Maria L.V. ; Rao, Rakesh ; Hamrick, Shannon E. ; Zaniletti, Isabella ; Digeronimo, Robert ; Natarajan, Girija ; Kaiser, Jeffrey R. ; Flibotte, John ; Lee, Kyong Soon ; Smith, Danielle ; Yanowitz, Toby ; Mathur, Amit M. ; Massaro, An N. / Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. In: BMC Pediatrics. 2019 ; Vol. 19, No. 1.
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abstract = "Background: While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods: Children's Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks' gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results: Ninety-five percent (range: 83-100{\%}) of patients with electrographic seizures, and 26{\%} (0-81{\%}) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6{\%}), followed by levetiracetam (16.9{\%}), phenytoin/fosphenytoin (15.6{\%}) and others (2.4{\%}; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was 89.90 (IQR 24.52,258.58). Conclusions: Amongst Children's Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.",
author = "Dizon, {Maria L.V.} and Rakesh Rao and Hamrick, {Shannon E.} and Isabella Zaniletti and Robert Digeronimo and Girija Natarajan and Kaiser, {Jeffrey R.} and John Flibotte and Lee, {Kyong Soon} and Danielle Smith and Toby Yanowitz and Mathur, {Amit M.} and Massaro, {An N.}",
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Dizon, MLV, Rao, R, Hamrick, SE, Zaniletti, I, Digeronimo, R, Natarajan, G, Kaiser, JR, Flibotte, J, Lee, KS, Smith, D, Yanowitz, T, Mathur, AM & Massaro, AN 2019, 'Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs', BMC Pediatrics, vol. 19, no. 1, 67. https://doi.org/10.1186/s12887-019-1441-7

Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs. / Dizon, Maria L.V.; Rao, Rakesh; Hamrick, Shannon E.; Zaniletti, Isabella; Digeronimo, Robert; Natarajan, Girija; Kaiser, Jeffrey R.; Flibotte, John; Lee, Kyong Soon; Smith, Danielle; Yanowitz, Toby; Mathur, Amit M.; Massaro, An N.

In: BMC Pediatrics, Vol. 19, No. 1, 67, 27.02.2019.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Practice variation in anti-epileptic drug use for neonatal hypoxic-ischemic encephalopathy among regional NICUs

AU - Dizon, Maria L.V.

AU - Rao, Rakesh

AU - Hamrick, Shannon E.

AU - Zaniletti, Isabella

AU - Digeronimo, Robert

AU - Natarajan, Girija

AU - Kaiser, Jeffrey R.

AU - Flibotte, John

AU - Lee, Kyong Soon

AU - Smith, Danielle

AU - Yanowitz, Toby

AU - Mathur, Amit M.

AU - Massaro, An N.

PY - 2019/2/27

Y1 - 2019/2/27

N2 - Background: While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods: Children's Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks' gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results: Ninety-five percent (range: 83-100%) of patients with electrographic seizures, and 26% (0-81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was 89.90 (IQR 24.52,258.58). Conclusions: Amongst Children's Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.

AB - Background: While intercenter variation (ICV) in anti-epileptic drug (AED) use in neonates with seizures has been previously reported, variation in AED practices across regional NICUs has not been specifically and systematically evaluated. This is important as these centers typically have multidisciplinary neonatal neurocritical care teams and protocolized approaches to treating conditions such as hypoxic ischemic encephalopathy (HIE), a population at high risk for neonatal seizures. To identify opportunities for quality improvement (QI), we evaluated ICV in AED utilization for neonates with HIE treated with therapeutic hypothermia (TH) across regional NICUs in the US. Methods: Children's Hospital Neonatal Database and Pediatric Health Information Systems data were linked for 1658 neonates ≥36 weeks' gestation, > 1800 g birthweight, with HIE treated with TH, from 20 NICUs, between 2010 and 2016. ICV in AED use was evaluated using a mixed-effect regression model. Rates of AED exposure, duration, prescription at discharge and standardized AED costs per patient were calculated as different measures of utilization. Results: Ninety-five percent (range: 83-100%) of patients with electrographic seizures, and 26% (0-81%) without electrographic seizures, received AEDs. Phenobarbital was most frequently used (97.6%), followed by levetiracetam (16.9%), phenytoin/fosphenytoin (15.6%) and others (2.4%; oxcarbazepine, topiramate and valproate). There was significant ICV in all measures of AED utilization. Median cost of AEDs per patient was 89.90 (IQR 24.52,258.58). Conclusions: Amongst Children's Hospitals, there is marked ICV in AED utilization for neonatal HIE. Variation was particularly notable for HIE patients without electrographic seizures, indicating that this population may be an appropriate target for QI processes to harmonize neuromonitoring and AED practices across centers.

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U2 - 10.1186/s12887-019-1441-7

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JO - BMC Pediatrics

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