the perinatal periods of risk approach sanil thomas ms biostatistics candidate april 27, 2010
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The Perinatal Periods of Risk Approach
Sanil ThomasMS Biostatistics candidate
April 27, 2010
Introduction
• Infant mortality rate (IMR) is a critical indicator of nation’s health
• IMR remains higher in United States than in other industrialized countries
• But IMR does not provide sufficient information to understand the factors that contribute to infant mortality
Introduction
• Traditional methods don’t include the fetal death counts for the analysis of mortality rates
• Fetal-infant mortality is a multi dimensional issue and a detailed analytical approach to fetal- infant mortality is needed to focus community initiatives for improving maternal and infant health.
Objectives
• To look at Feto-Infant mortality in a new way
• Apply PPOR framework for New York State
• To see the distribution of common risk factors by county level
Perinatal Periods of Risk (PPOR) Approach
• The Perinatal Periods of Risk Approach was developed by Dr. Brian McCarthy from the W.H.O. Perinatal Collaborative Center at CDC and other W.H.O. colleagues.
• Simple method that is based on a strong conceptual
prevention
• The PPOR Data allow you to look at feto-infant mortality in new ways
PPOR : 6 Basic Steps
Step 1: Assure Analytic and Community Readiness Step 2: Conduct Analytic Phases of PPOR Step 3: Develop Strategic Actions for Targeted
Prevention Step 4: Strengthen Existing and/or Launch New
Prevention InitiativesStep 5: Monitor and Evaluate ApproachStep 6: Sustain Stakeholder Investment and Political
Will
Analytic Phases of PPOR
Phase 1: Identifies populations and periods of risk with the largest excess mortality.
Phase 2: Explains why the excess deaths occurred.
PPOR Examines Deaths in TWO dimensions simultaneously:
• Age at death
• Weight at birth
Conce
ption
Birth 1
Year
Fetal Infancy20 wks 28 wks
4 wks
Spontaneous Abortion
Early Fetal
Late Fetal Neonatal
Postneonatal
Infant
Feto-Infant
Age at Death
The First Dimension Of PPOR Analysis:
Second Dimension: Birthweight
• Very Low Birthweight (PPOR limit)= less than 1500 grams (3.3 pounds)
• Low Birthweight= less than 2500 grams (5.5 pounds)
• Normal Birthweighte.g., a 7.5-pound baby weighs 3,400 grams
Birth
weig
ht
PPOR “Map” fetal & infant deaths
Age at Death
Birth
weig
ht
500-1499 g
1500+ g
Fetal
(24+
wks
)
Neonat
al
Postneo
natal
1 2 3
54 6
PPOR “Map” fetal & infant deaths
500-1499 g
1500+ g
Fetal Death Neonata
l
Post- neonata
lMaternal Health/
Prematurity
Maternal Care
Newborn Care
Infant Health
Birth
wei
gh
t
Age at Death
PPOR is about ACTION(each period of risk is associated with a set of possible areas for action)
Maternal Health/ Prematurity
Maternal Care
Newborn Care
Infant Health
Preconception Health Health Behaviors Perinatal Care
Prenatal Care High Risk Referral Obstetric Care
Perinatal Management Neonatal Care Pediatric Surgery
Sleep Position Breast Feeding Injury Prevention
PPOR: Phase 2
• Poisson log linear modeling• Covariates/Fixed effects
a. Mother’s race
b. Mother’s education
c. Mother’s age
d. Payor • Random effect - County
PPOR: Phase 2
• Fetal death was not used
• 2004-2007
• Predicted death counts were used to obtain smoothed death rates
• Modeling done for each countyRelative risk calculated from the beta estimates
Data
• New York State Dept. of Health. a. Electronic records of births
b. Linked birth-death cohort
c. selected fetal deaths
Phase 1 : 2003-2007 Phase 2 : 2004-2007
Software used
• SAS
• Excel
• ArcGIS
Results
Phase 1 ResultsObs County
Total number of deaths
Sum of Live births and Fetal
deaths
Death rates per 1000 live births and Fetal deaths
(PPOR categories)
Total DeathMaternal
health/prematurity
Maternal care Newborn care Infant health
1 ST LAWRENCE 61 6215 9.81 2.74 2.25 2.74 2.09
2 BROOME 101 10438 9.68 3.35 2.59 1.92 1.82
3 OSWEGO 62 6884 9.01 2.91 3.63 1.45 1.02
4 BRONX 1015 112785 9.00 4.34 2.66 0.79 1.21
5 JEFFERSON 76 8523 8.92 3.40 3.17 1.29 1.06
6 SCHENECTADY 76 9142 8.31 3.17 2.30 1.31 1.53
7 KINGS 1607 201738 7.97 3.66 2.35 0.86 1.10
8 ONEIDA 101 12905 7.83 2.40 1.55 1.63 2.25
9 ULSTER 72 9212 7.82 2.93 1.85 1.41 1.63
10 ALBANY 120 15904 7.55 3.58 1.76 0.75 1.45
11 RENSSELAER 66 8822 7.48 2.83 1.70 1.13 1.81
12 ERIE 373 50694 7.36 2.88 2.05 1.12 1.30
13 ONONDAGA 197 27648 7.13 2.89 1.77 1.23 1.23
14 QUEENS 990 153600 6.45 2.85 1.93 0.69 0.97
15 MONROE 273 43613 6.26 2.64 1.44 0.87 1.31
16 NEW YORK 629 102684 6.13 2.69 2.01 0.56 0.87
17 NIAGARA 70 11444 6.12 2.97 0.96 0.87 1.31
18 ORANGE 159 26316 6.04 2.24 1.25 1.18 1.37
19 RICHMOND 171 29176 5.86 3.29 1.34 0.55 0.69
20 ROCKLAND 134 23110 5.80 2.08 1.51 1.51 0.69
21 WESTCHESTER 342 61189 5.59 2.27 1.31 1.14 0.87
22 SUFFOLK 531 96216 5.52 2.53 1.29 0.91 0.79
23 NASSAU 411 77325 5.32 2.16 1.33 0.69 1.14
24 SARATOGA 60 11946 5.02 2.18 1.26 0.75 0.84
25 DUTCHESS 71 15763 4.50 2.03 0.38 1.33 0.76
Phase 1 Results
New York State
Death Rates per 1000 live births and fetal deaths
2.58Maternal Health/ Prematurity
1.63 Maternal
Care
1.12 Newborn
Care
1.21Infant
Health
Phase 2 Results
Poisson Log Linear model estimatesSolutions for Fixed Effects
Effect mom_race mom_educn mom_age payor EstimateStandard
Error DF t Value Pr > |t|Intercept -5.7132 0.06320 56 -90.40 <.0001
mom_race asian -0.1806 0.1431 2730 -1.26 0.2071
mom_race black_alone 0.9248 0.05255 2730 17.60 <.0001
mom_race other_races 0.1056 0.07598 2730 1.39 0.1646
mom_race z_white_alone 0 . . . .
mom_educn HighSchoolorAssoc 0.4346 0.05602 2730 7.76 <.0001
mom_educn lessthan_HighSchool 0.6420 0.07174 2730 8.95 <.0001
mom_educn z_Bachelors&above 0 . . . .
mom_age 35&above 0.1367 0.05468 2730 2.50 0.0125
mom_age lessthan20 0.2512 0.06412 2730 3.92 <.0001
mom_age z_20to34 0 . . . .
payor medicaid 0.03220 0.04705 2730 0.68 0.4937
payor other 0 . . . .
Conclusions
• Infant mortality Higher risk ratio for black mothers relative to white mothers Higher risk ratio for mothers having education less than high school when
compared to mothers having education more than bachelors Higher risk ratio for mothers of age less than 20 when compared to mothers
of age between 20 and 34
• Smoothed rates are higher in St.Lawrence, Erie, Schenectady, Oneida, Broome, Cortland etc
• Risk ratio for black mothers relative to white mothers are higher in the counties Orleans, Oswego, Chenango and Cortland
Limitation
• Missing data 12428 records out of 497787 records 246 deaths
• Inconsistent fetal data
Future study
• Detailed Phase 2 analysis including fetal deaths• MHP and IH categories – Protocol for Phase 2
studies
• Cluster Analysis• Spatial smoothing analysis
Reference
• http://www.citymatch.org/ppor_index.php
• Cai, J, Hoff GL, Dew PC et al. Perinatal periods of risk: analysis of fetalinfant mortality rates in Kansas City, Missouri. Matern Child Health J.2005;9:199-205
• Cai J, Hoff GL, Archer R et al. Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri. J Public Health Manage Pract. 2007;13:270-277.
Acknowledgments
• Dr. Glen D. Johnson, PhD, MS, MA• Dr. Marilyn A. Kacica, M.D.,M.P.H
Questions???
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