Ohio Perinatal Quality Collaborative Michele C. Walsh, MD, MSEpi,a, b Moira Crowley, MD,a,b Scott Wexelblatt, MD,c, d Susan Ford, RN, MSN,a ImprovesPierce Kuhnell, BS,e Heather C. CareKaplan, MD, MS, ofc, d Richard Neonatal McClead, MD,f,g Maurizio Macaluso, MD, PhD,c,d c,d CaroleNarcotic Lannon, MD, MPH, forAbstinence the Ohio Perinatal Quality Collaborative Syndrome OBJECTIVES: ’ abstract Neonatal abstinence syndrome (NAS) after an infant s in-utero exposure to opioids has increased dramatically in incidence. No treatment standards exist, leading to substantial variations in practice, degree of METHODS: opioid exposure, and hospital length of stay. The Ohio Perinatal Quality Collaborative conducted an extensive aDivision of Neonatology and Department of Pediatrics, multi-modal quality improvement initiative with the goal to (1) standardize Rainbow Babies & Children’s Hospital, Cleveland, Ohio; identification, nonpharmacologic and pharmacologic treatment in level-2 bDepartment of Pediatrics, Case Western Reserve University, Cleveland, Ohio; cAnderson Center for Health and 3 NICUs in Ohio, (2) reduce the use of and length of treatment with Systems Excellence and eDivision of Biostatistics and opioids, and (3) reduce hospital length of stay in pharmacologically treated Epidemiology, Cincinnati Children’s Medical Center, RESULTS: d newborns with NAS. Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio; fDepartment of Pediatrics, Fifty-two of 54 (96%) Ohio NICUs participated in the collaborative. Nationwide Children’s Hospital, Columbus, Ohio; and gDepartment of Pediatrics, Ohio State University, Columbus, Compliance with the nonpharmacologic bundle improved from 37% to Ohio 59%, and the pharmacologic bundle improved from 59% to 68%. Forty- Dr Walsh helped conceptualize this work, eight percent of the 3266 opioid-exposed infants received pharmacologic was a leader in the implementation of the treatment of symptoms of NAS, and this rate did not change significantly policies described, was the primary writer across the time period. Regardless of the opioid used to pharmacologically of the manuscript, and critically revised the treat infants with NAS, the length of treatment decreased from 13.4 to 12.0 manuscript; Drs Crowley, Wexelblatt, and Kaplan CONCLUSIONS: helped conceptualize this work, were leaders days, and length of stay decreased from 18.3 to 17 days. in the implementation of the policies described, Standardized approaches to the identification and and revised the manuscript; Ms Ford helped conceptualize this work and was a leader in the nonpharmacologic and pharmacologic care were associated with a implementation of the policies described; Mr reduced length of opioid exposure and hospital stay in a large statewide Kuhnell conducted the original analyses; Dr McClead collaborative. Other states and institutions treating opioid-exposed infants helped conceptualize this work, was a leader in the implementation of the policies described, and may benefit from the adoption of these practices. revised the manuscript; Dr Macaluso contributed to the design of the analyses and revisions to the manuscript; Dr Lannon helped conceptualize this ’ Neonatal abstinence syndrome (NAS) increased from 1.20 to 3.39 per 1000 work, was a leader in the implementation of policies described, and critically revised the manuscript; after an infant s in-utero exposure to births. All racial and ethnic groups – and all authors have approved the final manuscript are affected. The increase is described opioids has increased1,2 dramatically 5 7 as submitted and agree to be accountable for all in incidence. In 2011, 1.1% of both nationally and internationally. aspects of the work. pregnant women in the United States A standardized protocol for the DOI: https://doi.org/10.1542/peds.2017-0900 misused opioids, including3 pain treatment of NAS does not exist. Accepted for publication Dec 4, 2017 relievers and heroin. Up to 12.9% Nonpharmacologic measures, of women were dispensed an opioid including swaddling, skin-to-skin 4 To cite: Walsh MC, Crowley M, Wexelblatt S, et al. during pregnancy. Between 2000 care, and reduced stimulation are Ohio Perinatal Quality Collaborative Improves and 2010, maternal antepartum recommended and are intuitively Care of Neonatal Narcotic Abstinence Syndrome. opioid use increased from 1.19 to 5.63 appealing, despite lacking evidence Pediatrics. 2018;141(4):e20170900 per 1000 hospital births annually. of efficacy. Pharmacologic support Correspondingly, the diagnosis of NAS with opioids, including morphine, Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 4, April 2018:e20170900 QUALITY REPORT Interventions: Care – methadone, and buprenorphine, Data from the first 3 months of the is often used; yet, none of these initiative (January 2014 March A key driver diagram (Fig 1) medications has been shown 2014) were used as the baseline. The summarizes our theory for conclusively to be superior. Few project protocol was considered QI improvement. Our aim was to reduce studies of secondary agents including and not human subjects research ’ the length of opioid exposure and phenobarbital and clonidine exist. by the institutional review board of duration of hospitalization by using In animal models, all narcotics the Cincinnati Children s Hospital a multifactorial approach, which alter neuronal connections in the Medical Center. All participating included the following: developing brain; thus, reducing the NICUs received documents to review total opioid exposure of infants while with their institutional review board 1. Prenatal identification: counseling still humanely treating withdrawal and legal departments to confirm of opioid-exposed women in symptoms is desirable. the status of not human subjects partnership with obstetricians, researchOhio Perinatal. Quality Collaborative neonatologists, and addiction We previously reported the treatment specialists; development of an optimized pharmacologic protocol. The protocol 2. Improved recognition and support includes standardized guidelines for The Ohio Perinatal Quality of narcotic-exposed women and scoring NAS, triggers for initiation Collaborative (OPQC) is a state-based their infants: enhanced staff understanding of substance abuse of treatment, and a8, 9stringent network of Ohio perinatal clinicians, weaning protocol. We found that hospitals, professional organizations, as a chronic illness and of trauma- protocol use with stringent weaning and state agencies with a mission to informed care, encouraged guidelines reduced the duration reduce preterm births and improve partnering with the substance- of opioid exposure and length of outcomes for infants. Participating exposed mother, and training in nonjudgmental care. Training hospital8,9 stay, regardless of the opioid hospitals and clinicians are was completed by using a video used. supported by a central staff with QI “ created by the Vermont Oxford expertise and an administrative and ” In a pilot group of hospitals, we 7 Network on NAS entitled Nurture NICUdata managementParticipants infrastructure.and Patient 10 supplemented the standardized the Mother-Nurture the Child Population pharmacologic protocol with an and through panels of in-recovery optimized nonpharmacologic care mothers of infants with NAS who bundle. The nonpharmacologic shared their personal stories at bundle emphasized compassionate All level-2 and 3 Ohio NICUs and collaborative learning sessions. trauma-informed care for the their affiliated level-1 units were We encouraged care in the lowest ’ mother-infant dyad, keeping mother eligible. Level-1 units were typically acuity setting, together with and infant together, and standardized aggregated with their level-2 or 3 the infant s mother and family, scoring of NAS symptoms by hospital counterpart, although 2 promoting breastfeeding for “ ” nurses trained to a standard of high level-1 nurseries with a large volume those in a recovery program. We reliability. This report describes a of infants with NAS submitted data selected the FIR Square program quality improvement (QI) initiative independently. Twenty-six of 26 in British Columbia, 11Canada, as the to spread the NAS pharmacologic and (100%) level-3 NICUs, 26 of 28 model for ideal care ; nonpharmacologic care bundles to all (93%) level-2 NICUs, and 2 level-1 3. Attained high reliability on NAS level-2 and 3 NICUs in Ohio. The aim units participated. Units formed scoring: used a standardized for this project was to reduce length multidisciplinary teams with a ’ program (modified Finnegan of stay by 20% among term infants physician, nurse, social worker, – Scoring System; D Apolito training with NAS by June 2015 through dietician, and consulting addiction 12 14 ≥ ’ videos) ; identification and compassionate specialist. Infants were included treatment of withdrawal. if they were born 37 weeks 4. Optimized nonpharmacologic METHODS gestation, had evidence of in utero treatment (see key driver opioid exposure, and were cared for diagram) by promoting maternal ’ Study Design in a participating center. Data were involvement, breastfeeding if collected on those with symptoms mother s addiction specialist and pharmacologic treatment. We judged mother stabilized, We conducted a multisite QI excluded infants with symptoms of swaddling, skin-to-skin care, and initiative. The intervention began in NAS related to therapeutic opioid reduced stimulation. In infants ’ January 2014 and continued for 18 exposure, and premature infants who were not breastfeeding, the consecutive months to June 2015. <37 weeks gestation. use of low-lactose formula was Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 WALSH et al FIGURE 1 Key driver diagram for OPQC to Improve the Care of Newborns with In-Utero Narcotic Exposure. CPS, Child Protective Services; DHS, Department of Human Services; MBM, maternal breast milk; MD, medical doctor; RN, registered nurse.
encouraged on the basis8, 9of expert weaning, and use of secondary opioids; legislation passed in opinion and pilot work. The pharmacologic agents; January 2015 made such use use of 22-calorie formula was mandatory before prescribing. 6. Established a plan for safe encouraged but not required; discharge by partnering with Materials used by teams are available families to provide support to for download on the OPQC Web 5. Used Standardized NAS mother and infant post discharge. site (www.opqc .net/ projects/NAS). Pharmacologic Protocol (see Ensured a seamless transition Materials may be used by hospitals Supplemental Information): to outpatient medical care and withQI Methods attribution. supportive services for substance- a. Selected primary opioid exposed mothers; and (morphine or methadone) as The OPQC used standardized standard for all infants with NAS 7. Partnered with hospitals and state QI methods adapted from the at the hospital; and agencies to emphasize primary prevention: educated State Boards Breakthrough ’ b. Adopted or modified the Ohio of Medicine, Nursing, Pharmacy, Series Model of the Institute 16 Children s Hospital 15Association and Dentistry of opioid epidemic for Healthcare Improvement. Treatment Protocol that and role of prescribers in initial Multidisciplinary NICU teams included a standardized opiate exposure. Encouraged participated in collaborative approach to initiation of use of online record of Opiate learning activities, including 3 1-day treatment, escalation if needed, Prescriptions before prescribing face-to-face sessions and monthly Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 4, April 2018 3 Webinars facilitated by QI and with either or both of these events), applied commonly accepted rules for content experts. These activities an important modifier of the primary identifying special cause and shifting provided opportunities to review outcome measures. centerlines, including observing at protocols and QI methods, share least 8 consecutive points above or The primary outcome measures were data, and discuss team successes and below the centerline, or observing 1 the length of pharmacologic opioid 18 challenges. QI consultants worked point outside the control limits. treatment (measured in days from with NICU sites individually to RESULTS initiation to discontinuation) and identify barriers and test changes. length of hospital stay (measured During the 18 months, each team “ from admission to discharge). In was counseled to use the Model ” previous work, we found a strong Fifty-four units participated in the QI for Improvement ( Plan-Do-Study- correlation between total opioid dose collaborative and were included in Act method) to implement bundle 8 this analysis. Of these, 48 were NICUs exposure and length of stay. Thus, in ’ components. Each team used center this voluntary collaborative, we chose with an attached maternity hospital, specific data to identify areas for the less labor-intensive measure of and 6 were children s hospitals. improvement and implemented length of stay as a proxy for the more Sixteen (30%) of the participating sequential Plan-Do-Study-Act cycles meaningful measure of total opioid NICUs trained residents and 13 guided by the key driver diagram. exposure. For evaluation of the (24%) trained neonatal fellows. Centers entered data monthly into – primary outcome, we plotted infants We identified 3266 opioid- a Health Insurance Portability according to their birth month. Thus, exposed term infants. All infants and Accountability Act compliant improvements may reflect changes received treatment with the Internet-based system with rules instituted in previous months. nonpharmacologic bundle. Across the to improve data quality. Data were Analyses collaborative, 1570 (48.1%) infants reviewed monthly for potential required pharmacologic treatment errors; teams were asked to resolve of symptoms of NAS. The number of concerns. Source data were not In primary analyses, we examined pharmacologically treated infants audited. Data were analyzed by changes in aggregate results, with NAS ranged from 495 in the OPQC staff and provided to teams regardless of the treatment protocol hospital with the largest cohort in monthly reports that included used by the 54 units. Run charts to only 2 infants in the hospital individual site and aggregate results. were initially used to detect changes Process and Outcome Measures with the smallest cohort. Of the in processes and outcomes. For the pharmacologically treated infants, primary outcomes, the length of 17.9% were hospitalized in a level-1 opioid treatment and hospital stay nursery, 21.8% were hospitalized in Nonpharmacologic process measures baseline mean was calculated from a level-2 nursery, and 60.3% were included an all-or-none measure January 2014 to March 2014. The hospitalized in a level-3 NICU. Thirty of compliance that required 3 baseline mean was carried forward hospitals (56%) chose a standardized components: swaddling, low and displayed throughout the morphine protocol and 19 (35%) stimulation or rooming in, and breast intervention period. We planned to chose a standardized methadone milk (if appropriate) or low-lactose convert run charts to control charts 17 protocol, whereas 5 (9%) used other feeds or both. Optional measures when sufficient data were acquired. Processprotocols Measures. included the use of 22-kcal formula, We converted all run charts into and clothed cuddling or kangaroo control charts displaying centerlines Nonpharmacologic Bundle Compliance care. Each bundle component was and control limits for key measures. also analyzed separately to guide Because the 2 key outcomes (length teams to foci of improvement. of treatment and length of stay) We saw significant improvements The second process measure was follow highly skewed distributions, in the implementation of the compliance with the pharmacologic we used log-transformed values in nonpharmacologic bundle. The bundle that was defined as an a regression analysis of time trends; control chart shows special cause, all-or-none measure requiring 3 for these trends, we used generalized with compliance for all components components: treatment initiated linear mixed models that accounted of the bundle increasing by 21 appropriately, unit primary opiate for clustering by hospital and serial percentage points from 37.1% given, and weaning begun 48 hours autocorrelation. We then converted to 59.4% by April 2014 (Fig 2A). after stabilization. An intermediate the adjusted mean measures and The component that was the most ’ process measure was the frequency their confidence boundaries back to difficult to move was provision of of dose escalation, or failed weaning the natural scale of the observations mother s own milk or low-lactose (defined as the percentage of infants to construct the control charts. We feedings if breast milk feedings Downloaded from www.aappublications.org/news by guest on September 27, 2021 4 WALSH et al were judged to be contraindicated by illicit drug use. Over the entire ’ study period, on average, 17.5% of infants were fed only their mother s milk, 34.5% received a low-lactose formula, 7.4% received both, (total = 59.4%), and 15.6% of infants receivedPharmacologic 22-calorie Bundle formula Compliance (Fig 2B).
Data on compliance with the pharmacologic bundle were complicated by a change in the methadone treatment protocol at month 5 of the collaborative, driven by the19 results of a pharmacokinetic study, which led centers to report that they were not compliant with the Ohio protocol; this resulted in an underestimation of true compliance rates in standard reports for those hospitals using methadone. Thus, compliance is reported only among hospitals that chose morphine for opioid treatment. Among hospitals treating with morphine, pharmacologic bundle compliance increased from a baseline of 59% to 68%, an absolute increase of 11%. The control chart reveals evidence of special cause in early 2014 (Fig 3A). Treatment was initiated appropriately for 76% of infants, morphine was the opioid administered to 99%, weaning was started within 48 hours after stabilization in 84%, dose escalation was initiated after a failed weaning step in 65%, and a secondary medication was used in 38% (Fig 3B). The proportion of infants who failed a weaning step or required dose escalation is an important intermediate outcome FIGURE 2 that may directly affect the duration Compliance with the nonpharmacologic treatment bundle. A, Proportion of infants with NAS meeting of treatment and hospital stay. This the criteria for compliance: control chart showing a shift in centerline in July 2014. B, Proportion of infants with NAS meeting the criteria for compliance with individual elements of the bundle (average measure decreased significantly, with from January 2014 to June 2015). Breast milk or low-lactose feeds, swaddling, and low stimulation the control chart revealing special or rooming in are all required to be in compliance with the bundle. The 22-kcal/oz feeds, clothed cause in early 2014 and a shift in the cuddling, and other are all optional treatments. centerline from 67.4% to 59.4% Outcome(Fig 4). Measures (Length of Treatment and Length of Stay) had previously participated in During that work, these hospitals ’ the development and testing saw a decrease in the days of
The 6 children s hospitals in Ohio of a standardized approach 8 pharmacologic treatment from 33.8 and some of their affiliated centers to pharmacologic treatment. to 21.3 days and in length of stay Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 4, April 2018 5 special cause in early 2014, which led to a shift in the centerline from 13.4 to 12.0 days (a 9% decrease) (Fig 5A). Similarly, the geometric mean for length of stay revealed a significant 9% decrease, with the control chart revealing special cause in early 2014 and a shift in the centerline from 18.3 to 17.0 days (Fig 5B). DISCUSSION
In this statewide QI collaborative, we have shown that standardized training for neonatal nurses in scoring abstinence symptoms and trauma-informed care, together with standardized nonpharmacologic and pharmacologic bundles, was associated with a reduction in the duration of opioid exposure and hospital stay in opioid- exposed newborns. In addition, these reductions occurred on a background of previous work with the largest hospitals that had already reduced the length
of opioid8,9 treatment and length of stay. Thus, our observations are consistent with the change theory outlined in our key driver diagram. The ability to spread a complex protocol across 54 hospitals statewide is a testament to the urgency of the opioid epidemic as well as to the power of rigorous QI science and collaborative FIGURE 3 work. Reliable use of the Compliance with the pharmacologic treatment bundle in hospitals that chose morphine as the nonpharmacologic bundle improved primary opioid. A, Proportion of infants with NAS meeting the criteria for compliance: control chart over time but was less than optimal showing a shift in February 2014. B, Proportion of infants with NAS meeting the criteria for compliance with individual elements of the bundle (average from January 2014 to June 2015). Treatment initiated at 58%. High reliability was appropriately at a score ≥8 measured twice or >12 measured once, unit-designated primary opiate obtained for 2 components of the given, and weaning started after stable without dose escalation for 48 hours are all required to be bundle: the use of swaddling (95%) in compliance with the bundle. and low stimulation or rooming in (92%). Total bundle compliance ’ was lowered by the component focused on feeding: mother s from 30.1 to 20.2 days (data not over time, the geometric mean breast milk or low-lactose feeds or shown). for length of treatment showed a both. Suboptimal compliance may After adjustment for clustering significant decrease over the time relate to several factors, including within hospitals and autocorrelation period, the control chart revealing the weakness of the evidence Downloaded from www.aappublications.org/news by guest on September 27, 2021 6 WALSH et al “ ” saying, How could they do that to their baby? As part of a curriculum in trauma-informed care, site team members reported that learning that up to 40% of women with opioid addiction are victims
of child abuse, sexual abuse, or 25 both changed their perceptions. This change led them to welcome the mothers to the care team. Consequently, families felt more supported and spent more time on the units carrying for their infants. As the opioid epidemic overwhelms the nation, this attitudinal change is a critical component of obstetric and neonatal care. The evidence behind the pharmacologic bundle is relatively strong; however, there is still room FIGURE 4 for improvement. Compliance with Proportion of infants with NAS failing a weaning step or requiring an opioid dose escalation: control the bundle increased significantly chart showing a shift in centerline in March 2014. from 59% to 68% in hospitals that used morphine. Our data system did not allow a reliable assessment of compliance in hospitals that chose 21,24 methadone. High reliability was supporting the nonpharmacologic published expert opinion. Sites achieved with the use of a unit- bundles and institutional policies varied in their use of both low- designated opioid (99%) and with about the provision of breast milk lactose and higher-calorie formulas 20 the use of the weaning protocol in women exposed to opioids. during the QI collaborative. The (87%). The total compliance Roughly half the mothers of the scoring system used in all hospitals measure was reduced by the infants with NAS were using illicit was the modified Finnegan scoring component of treatment initiation opioids, were not in a treatment system, the most widely used (68%), which is influenced by the program, and were determined to scoring system in the United States. Finnegan scoring system. Thus, we not be appropriate to breastfeed. This system has been modified are confident that our methods for Twenty-four percent of the infants several times since its introduction promoting a uniform, standardized were fed breast milk from their in the mid-1970s and lacks approach to pharmacologic mothers, generally when they rigorous validation. Nevertheless, treatment were effective in were in treatment programs. This training nurses to high reliability reducing variability in treatment practice is consistent with the and ongoing recertification, practices. recommendations from leading particularly in lower-volume units, societies including the American was an important component of The improvements reduced the Congress of Obstetricians and improvement. The recommendation proportion of infants who failed a
Gynecologists and the American21,22 that infants with NAS receive care weaning step or required a dose Academy of Pediatrics. The in low-stimulation environments escalation. This is directly related small amount of opioid transferred is established practice;20 yet, it lacks to prolonged treatment and longer through breast milk is significantly systematic evaluation. stay at the hospital. Consistent with less than that transferred to the the improvements documented by infant in utero and may be used23 The inclusion of the mother as an this analysis, length of treatment and to treat withdrawal symptoms. active care partner was a significant length of stay decreased significantly. The formula recommendations shift for most hospitals. Many Although the 1.3-day, 9% reduction (use of low-lactose formula and health care workers view families in both measures is smaller than the consideration of using 22 kcal/oz.) of infants with NAS through a 20% effect desired as the aim of the were made on the basis of judgmental lens, thinking, or even collaborative, it was both statistically Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 141, number 4, April 2018 7 escalation) may lead to additional gains.
This statewide population included all infants exposed to opioids, rather than a selected subset. Thus, the work is likely to be generalizable to all populations of term infants with NAS. One possible limitation is that the protocol was ’ implemented after standardization of care in the 6 children s hospitals and affiliates. Because this previous work had already demonstrated substantial reductions in duration of opioid treatment and length of stay, the changes that we report are likely to underestimate the true impact of standardizing care in settings that have not used this previously.
CONCLUSIONS
Standardized approaches to the identification and nonpharmacologic and pharmacologic care were associated with a reduction in the length of opioid exposure and hospital stay in a large statewide collaborative. Further refinements of the program may lead to additional gains. Other states and institutions treating opioid-exposed infants may benefit from consideration of these practices. ACKNOWLEDGMENTS
We thank the brave women in FIGURE 5 OPQC outcome measures. A, Average length of treatment (geometric mean): control chart showing recovery who shared their insights a shift in centerline in September 2014. B, Average length of stay (geometric mean): control chart regarding the journey during showing a shift in centerline in September 2014. pregnancy in-person at a learning session with over 500 participants; their stories informed our work and led to more compassionate treatment of families who are significant and clinically important, strengthening the program and opioid-exposed. We thank the given the large number of infants focusing on creating a stronger teams at all participating hospitals who experienced NAS: an overall impact on the key intermediate for their diligence and for providing reduction of 2041 hospital days. variables (eg, preventing weaning the data that supports this work. Our findings suggest that failures and the need for dose A list of participating hospitals Downloaded from www.aappublications.org/news by guest on September 27, 2021 8 WALSH et al ABBREVIATIONS is found in the Supplemental providing access to materials from Information. We also thank Ron their Collaborative to Improve Abrahams, MD, Director of the Fir the Care of NAS Infants. Neither NAS: neonatal abstinence Square Combined Care Program, Dr Abrahams nor the staff at the syndrome British Columbia, Canada for OPQC: Ohio Perinatal Quality Vermont Oxford Network assisted sharing details of their program Collaborative in the analyses or development of with OPQC. Finally, we thank the QI: quality improvement Vermont Oxford Network for the manuscript. Address correspondence to Michele C. Walsh, MD, MSEpi, Department of Pediatrics, Rainbow Babies & Children’s Hospital, 11100 Euclid Ave, Mailstop 6010, Cleveland, OH 44106-6010. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2018 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. The Ohio Perinatal Quality Collaborative Neonatal Abstinence Syndrome Project is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this publication are solely those of the authors and do not represent the views of the state of Ohio or federal Medicaid programs. FUNDING: The Ohio Perinatal Quality Collaborative is funded by the Ohio Department of Medicaid through the Medicaid Technical Assistance and Policy Program and administered by the Ohio Colleges of Medicine Government Resource Center. The funders had no role in data analysis or manuscript development. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/early/2018/03/05/peds.2017-0900
Data Supplement at: http://pediatrics.aappublications.org/content/suppl/2018/03/05/peds.2017-0900.DCSupplemental
Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2018 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.
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