Proportion of Infants 22 to 29 Weeks Gestation Treated with Surfactant who are Treated within 2 Hours of Birth (NQF 0484)

eMeasure Name Proportion of Infants 22 to 29 Weeks Gestation Treated with Surfactant who are Treated within 2 Hours of Birth eMeasure Id C9324AE3-524F-4348-A8FA-C036406297C6
Version number 1 eMeasure Set Id 974AE0AB-308B-4724-9DFE-22A0B06C4E81
Available Date No information Measurement Period January 1, 20xx through December 31, 20xx
Measure Steward Vermont Oxford Network
Endorsed by National Quality Forum
Description Proportion of infants with gestational age between 22 and 29 completed weeks who were treated with surfactant and were treated within two hours of birth.
Copyright
Measure scoring Proportion
Measure type Process
Stratification
This measure is stratified by birth location, which includes inborn infants, outborn infants, and all eligible infants.
Risk Adjustment
None
Data Aggregation
Rationale
Meta-analyses of randomized controlled trials show that surfactant replacement, given as prophylaxis or rescue treatment, reduces the incidence and severity of respiratory distress syndrome, air leaks, and mortality in preterm infants with surfactant deficiency (Engle 2008).  Prophylactic surfactant administration to infants of less than 30 weeks' gestation reduces mortality, the frequency and severity of respiratory distress syndrome, air leaks, and the combined outcome of bronchopulmonary dysplasia and death compared with infants who receive placebo or rescue surfactant (Soll 2000). Early rescue surfactant (<2 hours from birth) given to infants of less than 30 weeks' gestation reduces the frequency of adverse respiratory outcomes compared with later rescue surfactant (Yost 2000).  Despite this evidence, delayed surfactant treatment occurs frequently and the proportion of infants treated within 2 hours of birth varies markedly among hospitals (Horbar 2004a). For 22 to 29 week gestation infants born in 2009 and reported to the Vermont Oxford Network by 850 participating hospitals, 79% were treated with surfactant.  Thirteen percent of all infants received the first dose of surfactant after 2 hours of age.  Fewer than 3% of infants were first treated beyond 2 hours at the 25% of hospitals with the lowest rates, whereas over 20% of infants were first treated beyond 2 hours at the 25% of hospitals with the highest rates (VON 2009 unpublished). In a cluster randomized trial conducted at 117 hospitals it was shown that a multifaceted intervention to promote evidence-based surfactant therapy significantly reduced the proportion of infants receiving the first dose of surfactant more than 2 hours after birth (adjusted OR 0.35, 95% CI 0.24-..53) (Horbar 2004b).  

The randomized controlled trials demonstrating the benefits of earlier surfactant therapy were conducted in populations with relatively low rates of exposure to antenatal steroids.  It is possible that the benefits of earlier surfactant therapy may be reduced in current populations where antenatal steroid exposure is higher.   However, there is also evidence that antenatal steroids and surfactant are synergistic, raising the possibility that there may be added benefits of surfactant treatment in infants exposed to antenatal steroids (Jobe 2004).

Neonatologists may attempt to avoid endotracheal intubation and surfactant administration by treating infants with nasal CPAP soon after birth (Morley 2008, SUPPORT 2010).   Since this practice may lead to delayed surfactant therapy in those infants who eventually require endotracheal intubation and surfactant treatment, the measure is stratified by early CPAP status.  Since outborn infants are more likely than inborn infants to have delayed surfactant therapy, the measure may also be stratified by this variable.
Clinical Recommendation Statement
For those infants 22 to 29 completed weeks gestation requiring surfactant treatment, the treatment should be started within 2 hours birth.  There may be a tradeoff between the benefits of initiating early surfactant treatment and the benefits of avoiding endotracheal intubation and surfactant treatment by using early nasal CPAP.
Improvement notation
Higher score indicates better quality
Measurement duration
12 month(s)
Reference
Engle WA, and the Committee on Fetus and Newborn.  Surfactant-Replacement Therapy for Respiratory Distress in Preterm and Term Neonate.  Pediatrics 2008;121:419-432.
Reference
Horbar JD, Carpenter JH, Buzas J, et al. Timing of initial surfactant treatment for infants 23 to 29 weeks' gestation: is routine practice evidence based? Pediatrics. 2004;113:1593 –1602.
Reference
Horbar JD, Carpenter JH, Buzas J, et al. Collaborative quality improvement to provide evidence based surfactant for preterm infants: a cluster randomized trial. BMJ. 2004;329:1004
Reference
Jobe AH, Mitchell BR, Gunkel JH. Beneficial effects of the combined use of prenatal corticosteroids and postnatal surfactant on preterm infants.  Am J Obstet Gynecol. 1993;168 (2):508 –513
Reference
Morley CJ, et al.  Nasal CPAP or Intubation at Birth for Very Preterm Infants. N Engl J Med 2008;358:700-708.
Reference
Soll RF. Prophylactic synthetic surfactant for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2000;2:CD001079.
Reference
SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network.
Reference
Early CPAP versus Surfactant in Extremely Preterm Infants. N Engl J Med 2010;362:1970-1979.
Reference
Yost CC, Soll RF. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database Syst Rev. 2000;2 :CD001456.
Definition
Initial Patient Population(s): Infants with gestational age 22-29 completed weeks who were born in the reporting hospital (population 1) or admitted to the reporting hospital within 28 days of birth (without first being discharged home – population 2). Population 3 includes all infants meeting population 1 and population 2 criteria. The guidance section also recommends stratification of infants in each of the populations with respect to who received treatment by continuous positive airway pressure (CPAP) prior to receiving surfactant and ones that did not.
Definition
Denominator(s): Includes all infants in each of the respective populations who were treated with surfactant.
Definition
Denominator Exclusion(s): N/A
Definition
Numerator(s): Infants who were treated with surfactant within two hours of birth.
Definition
Denominator Exception(s): 1. Infants outside the gestational age range. 2. Out born infants who were discharged home from a hospital prior to admission at the reporting hospital. 3. Infants not treated with surfactant.
Guidance
The element "Transfer To: home" in this measure is intended to identify those infants who were born outside the hospital who were at home at any point before the admission to the current hospital. 

The measure could be further stratified by whether the infant received continuous positive airway pressure (CPAP). CPAP strata include infants who received CPAP prior to endotracheal tube ventilation, and infants who did not receive CPAP:

1) First identify infants that received CPAP at any time after leaving the Initial Resuscitation Area.
2) Next identify whether the infant received nasal CPAP without first having received positive pressure ventilation through an endotracheal tube.
3) Measure results will be stratified by the following categories:
   a) Nasal CPAP before ETT ventilation = YES (infant received nasal CPAP before ETT ventilation). This is referred to as early CPAP.
   b) Nasal CPAP before ETT ventilation = NO or Nasal CPAP = NP (infant either received ETT vent before nasal PAP or never received nasal CPAP).
   c) All infants who received surfactant regardless of whether or not they received early CPAP.

The gestational age of 29 weeks is in completed weeks, so this can be 29 weeks 6 days or 209 days.
Supplemental Data Elements
Report "Patient Characteristic: Gender" using "Gender HL7 Value Set (2.16.840.1.113883.1.11.1)"; Report "Patient Characteristic: Race" using "Race CDC Value Set (2.16.840.1.114222.4.11.836)"; Report "Patient Characteristic: Ethnicity" using "Ethnicity CDC Value Set (2.16.840.1.114222.4.11.837)"; Report "Patient Characteristic: Payer" using "Payer Source of Payment Typology Value Set (2.16.840.1.113883.3.221.5)".

Table of Contents


Population criteria

      ------ Population Criteria 1 ------

      ------ Population Criteria 2 ------

      ------ Population Criteria 3 ------

Data criteria (QDM Data Elements)

Supplemental Data Elements




Measure set CLINICAL QUALITY MEASURE SET 2011-2012