Prognosis of extremely premature infants linked to inherent selection bias
1. Demographic data, such as larger birth weight and female gender, of infants born at 23 weeks' gestation were shown to influence the chance that active resuscitation was initiated.
2. The decision to pursue aggressive medical management in infants born at 24 and 25 weeks' gestation was not shown to be linked with any particular demographic factor.
Evidence Rating Level: 2 (Good)
Study Rundown: Clinician choice to withhold intensive resuscitation for infants born at 23 weeks' gestation is partially guided by available prognostic data. However, this data itself is reflective of provider variability in pursuing aggressive care. This feedback loop may in fact worsen outcomes for neonates of this gestational age. The aim of this study was to define which characteristics of premature neonates influence providers' decision to pursue active medical management. The results indicated that infants born at 23 weeks' gestation were more likely to receive active therapy if their birth weight were larger and if they were female. These findings highlight how biological factors perceived to be favorable may ultimately affect provider decision-making. The results also lend evidence to the fact that the choice to pursue care should not solely be based on prognostic data alone, as it may be skewed. Although the study was unable to account for antenatal differences affecting survivability, such as steroid administration, it is strengthened by its large population size. Additionally, the inability to confirm that both populations from the data sets used are the exact same limits the scope of the study.
In-Depth [retrospective cohort]: Authors used 2 Australian data sets to evaluate prognostic factors for neonates born at 23, 24, and 25 weeks' gestation between 2010-2013. Rates of stillbirth and live-birth, along with other demographic factors, were collected from the Australian Institute of Health and Welfare data set. These data were then compared with neonatal intensive care unit (NICU) admission rates for presumably the same population, as published by the Australian and New Zealand Neonatal Network data set. Admission to the NICU was used as a surrogate for survivability and a determinate of the physicians' decision to pursue active care. The proportion of infants admitted to the NICU grew with increasing gestational age at birth (38% at 23 weeks, 80% at 24 weeks', and 90% at 25 weeks; adjusted P < .001). Additionally, 13% of infants born at 23 weeks' gestation weighing <500 grams were admitted to the NICU as compared to 43% of those weighing >500 grams (RR: 0.30, 95% Cl: 0.17-0.54, P < .001). Finally, female neonates that were 23 weeks' gestation were more likely to be admitted to the NICU compared with males of that gestational age (43% vs. 33% RR: 0.76; 95% Cl: 0.61-0.96, P = .018).
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