Assessment of an Updated Neonatal Research Network Extremely Preterm Birth Outcome Model in the Vermont Oxford Network

Abstract

Importance: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals.

Objective: To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States.

Design, setting, and participants: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019.

Exposures: Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids.

Main outcomes and measures: The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use).

Results: Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%).

Conclusions and relevance: An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Rysavy reported receiving grants from the National Institutes of Health (NIH) and travel funds from the Vermont Oxford Network (VON) during the conduct of the study. Dr Horbar reported receiving personal fees from VON outside the submitted work and serving as an unpaid member of the Board of Directors of VON. Dr Bell reported receiving grants from the NIH. Dr Tyson reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) during the conduct of the study and grants from the NICHD outside the submitted work. Dr Patel reported receiving grants from the NIH during the conduct of the study. Dr Carlo served as a paid member of the board of directors of Mednax and received grants from the NIH during the study. Dr Younge reported receiving grants from the NIH during the conduct of the study. Dr Green reported receiving grants from the NICHD during the conduct of the study. Dr Edwards reported receiving grants from VON during the conduct of the study. Dr Hintz reported receiving grants from the NICHD during the conduct of the study. Dr Walsh reported receiving grants from the NIH. Dr Das reported receiving grants from the NICHD and the NIH during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Odds Ratios for Survival in the Original and Updated Models

Odds ratios for birth at 22, 23, and 24 weeks’ gestation used birth at 25 weeks’ gestation as the reference category. Odds ratios for birth weight are per 100-g increase. Error bars indicate 95% CIs for survival.

Figure 2.. Observed and Model-Predicted Survival Rates in the Vermont Oxford Network (VON) 2006-2012 Cohort

Observed and model-predicted survival rates in the VON 2006-2012 cohort were compared for infants grouped by birth weight quartile for gestational age (75%), sex (male or female), plurality (singleton or multiple gestation), and exposure to antenatal steroids (yes or no) as presented in the development of the original model.