Feasible Restructuring For Treatment of Bronchiopulmonary Dysplasia (BPD) For MedArts By Kevin Davison Technical Writer Quevin, LLC March 2008

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INTRODUCTION There is no immediate solution to cure BPD and MedArts has the ethical responsibility to continue to provide its quality treatment of BPD with proper medical equipment, and certified medical professionals in its NBICU’s. Mortality rates have not changed since the application of experimental treatments, and the need for specialized care of BPD patients in MedArts newborn intensive care units (NBICU) is proven to be necessary. Surfactant replacement therapy (SRT) was hoped to eliminate BPD. However, chronic lung disease continues to develop in a significant number of premature infants. According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), between 5,000 and 10,000 cases of BPD occur every year in the United States. Preliminary tests reveal which infants are most at risk, and the complications related to BPD can compound fatality. This study evaluates the advantages and disadvantages of each feasible option based on providing BPD patients quality, cost-effective health care. This must be financially feasible for MedArts, and convenient enough for families involved to travel and feel close to their infants suffering from BPD. Hundreds of families and dozens of doctors were interviewed for this study. NelsonNygard, a Transportaion Planning Agency, was also contracted to supply transportation and geographic analysis for this evaluation. The feasible options are to remain in the status quo, decentralize the care of BPD, or centralize entirely at Longworth Pediatric Hospital (LPH). LPH is staffed with four certified pediatric pulmonologists or pediatric cardiologists. Although each MedArts hospital has adequate equipment and staffing to treat BPD, Fairfax Medical Center and Rivershore District Regional Hospital rely entirely on LPH for specialized care. Is the status quo still a financially viable way to provide quality treatment of BPD patients and their families? LPH is already providing adequate care, therefore, it may be more viable to centralize the care of BPD with less emphasis on Fairfax and Rivershore. This alleviates resources so LPH may continue providing the level of care it does. However, all hospitals do have adequate resources to treat BPD. It may be less of a financial burden to decentralize the approach of treating BPD, and spread resources equally between LPH, Farifax and Rivershore. The priority to consider is whether the provision of quality care is sustainable with either of these options.

How Does MedArts Continue To Provide The Best Quality Healthcare? The AAFP defines quality healthcare as “the achievement of optimal physical and mental health through accessible, cost-effective care that is based on best evidence, is responsive to the needs and preferences of patients and populations, and is respectful of patients’ families, personal values and beliefs.” MedArts is committed to providing patients quality, cost-effective health care. The highest priority is to provide the best and most responsive treatment, as ethically as possible. All hospitals have the equipment and medical staffing necessary to treat BPD, considering the status quo. However, certified pediatric pulmonologists reside at LPH and are in contact with neonatologists and pediatricians at Farirfax and Rivershore only by phone. Although all hospitals monitor closely for infection, LPH is the only one that has pediatric infectious disease specialists. This service disparity between the level of BPD care offered at LPH and other hospitals may degrade the overall quality of care that MedArts can provide. LPH is the only hospital prepared

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to treat all BPD complications. LPH is also the only hospital that has Extracorporeal Membrane Oxygenation (ECMO) capabilities and pediatric pulmonology. The time it takes to transport patients from other hospitals to LPH may result in the depletion of the quality care MedArts is committed to, and the overall safety of its patients. Nelson Nygard revealed that transportation delay and mobile treatment accessibility is a concern when considering centralization at LPH. The crucial moments between diagnosis and stabilization could cost the life of a patient, especially if there is mechanical failure during transport or traffic congestion. This may require frequent helicopter usage, which can increase costs. There will be better care available to the child if BPD results after a child is delivered at birth or brought directly to LPH. Unfortunately, if a child is delivered prematurely at Longworth or Fairfax and complications escalate to BPD. Children experience some risk or further complications without the specialized care available at LPH. Remote consultation by LPH may not be enough to match the level of care for Fairfax and Rivershore. Decentralization will offer more immediate care for patents in all three MedArts hospitals, without discrimination of BPD care. No single hospital will provide the highest care, and will be spread-out amongst the MedArts system. However, will this spread-thin the care that one specialized hospital could provide better? LPH already has the best care available to treat BPD. The certified pulmonologists may not want to relocate or commute to Fairfax or Rivershore. LPH presently has its how BPD unit, aside from the NBICU, so the other hospitals will either need to match this construction or utilize other space. The costs of construction may cost millions.

How Do The Financial Considerations Compare? While MedArts is dedicated to providing the best, quality healthcare, it is also important that the MedArts system can continue to offer quality treatment consistently, and as cost-effectively as possible. Some of the main cost considerations are mechanical equipment, emergency and medical transportation, medical staffing and providing family support for victims of BPD. It is still possible to continue to offer the level of quality healthcare with the status quo. Certified pulmonologists reside only at LPH and traveling wastes their time, which is costly. Nelson Nygard quantified that it could cost MedArts $100,000 per month in transportation costs and loss of doctor availability. However, interactive video confrencing technology may be available to solve this problem, and would range between $2,000 and $15,000. It depends on the number of units, and would still be a fraction of the costs calculated by Nelson Nygard’s findings. Video conferencing and remote manipulation of NBICU equipment may be possible with further evaluation of these services. LPH is the primary recipient of donations from various organizations to help families pay for treatment, which is one consideration for centralization to LPH, Fairfax and Rivershore do not presently have this kind of dedicated financial support for families. It may therefore be to the family’s advantage to request transfer to LPH, ultimately resulting in a more centralized result anyway. Pulmonologists are presently staffed at LPH, and the hospital has its own BPD unit, as well as an NBICU. However, the capacity of this hospital may not be sufficient to hold the increase of patients presently represented at Fairfax and Rivershore. There may need to be

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construction to accommodate the extra patients. While LPH is presently capable of providing multispecialty consultation, it may not be able to provide the same level of care to all patients with BPD in the MedArts system with the increased volume. The equipment used to treat BPD at Fairfax and Rivershore may be utilized at LPH, and possibly sold to finance increased needs from centralization at LPH. There will be more transportation costs to consider between hospitals for families who initially had their child at Fairfax or Rivershore, only to be taken to LPH. There is not only the patient emergency transportation to consider, but also the patient’s families, especially if they don’t have their own transportation. MedArts cares for the families of its patients, and wants to accommodate their need to be with the patient. As with the status quo, decentralization wouldn’t alter equipment and staffing, except for LPH. However, there may not be enough certified pulmonologits willing to staff Fairfax and Longworth. It also costs time and money to transfer doctors between locations The realized cost to transfer doctors between hospitals is clear, and the next consideration is how transportation requirements effect families with infants being treated with BPD throughout the MedArts system.

How Do Transportation Alterations Affect Patient’s Famililies? Parents and family members with infants suffering from BPD must also be accommodated so they can spend time comfortably with them. Each option has evaluated how doctors and patients will be affected. The options should evaluate how families will affected too. Of the hundreds of families interviewed for this study, 80% say they have had no trouble with transportation as-is, with the status quo. However, 15% were either incapable of traveling regularly to visit the hospital, or had special needs that required timely accommodation. For instance, one mother was confined to a wheelchair after the pregnancy, and didn’t have a way to get to the hospital without considerable effort. Considering centralization, most families interviewed throughout the region may not have adequate transportation to visit LPH regularly enough. Most families interviewed considered the status quo to be best suited to their needs. However, 90% agreed that quality care for infants with BPD is a higher priority. Therefore, they didn’t think transportation difficulty would alter their perspectives on the quality of care that MedArts would provide, as long as the infants with BPD are treated best. If MedArts decentralizes, LPH may need to provide more facilities for visiting family members, including transportation between other hospitals. Families will require improved access to their child, due to prolonged treatment of BPD at each location. If the quality of care can be maintained consistently throughout all MedArts locations, then families may feel more secure about the care of their infant. If pulmonologists are willing to relocate or commute to their new assigned locations, this will provide specialized care at all locations. However, will this dilute the care that is presently being provided at LPH by four in collaboration?

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CONCLUSIONS The table below compares feasible options considered in this study, based on the quality of healthcare, financial, and transportation criteria. Status quo Centralization Decentralization Quality of Healthcare X

Financial X Transportation X

Under the status quo, patients suffering from BPD have a better chance of survival at LPH if their situation requires multispecialty consultation or more intensive ECMO for treatment. However, most treatment provided by all hospitals in the MedArts system do have adequate staffing and capabilities to treat most cases of BPD in their NBICU’s. Transportation for patients and remote consultation doesn’t seem to be a problem. All hospitals have adequate systems to transport patients if necessary. Centralization provides a consolidated approach to the treatment of BPD at LPH. LPH has more than adequate staffing with certified pediatric pulmonologists and advanced systems like ECMO to treat the worst cases of BPD. The geographic location requires more consideration for transportation from Fairfax and Rivershore, and may require the use of a helicopter for cases that are too risky for ground transportation. Unfortunately, LPH may not have adequate space to provide immediately for centralization. Expansion may be required, which has financial implications, as well as disruption of service problems. Decentralization primarily accommodates the transportation of patients to one of the three locations in the MedArts system. Families have improved access to each location, and there would be less risk due to moving patients in need of treatment at another facility. However, this also requires that each location add their own BPD unit, ECMO, and certified pulmonologists on staff to treat even the worst cases. Financially, this is the most expensive option to consider.

POSSIBLE NEXT STEPS It would be useful to estimate the costs associated with each option to qualify whether either option is viable. Decentralization and the Status quo have the greatest costs related to equipment and staffing at Fairfax and Rivershore. LPH might have the staffing and equipment, but not the adequate space for a centralized approach. These construction costs could be estimated. It may also be helpful to hire a transportation planner to coordinate emergency routes between hospitals for the centralized option, since MedArts already knows this for status quo and a decentralized approach. Finally, it would be useful to survey the parents of existing BPD patient’s parents throughout the MedArts system about their transportation needs and how each option would affect them personally.