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Zupancic, John

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Zupancic

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Zupancic, John
Author's Publications: search.filters.isAuthorOfPublication.5374faa7-d365-4175-baa5-f90319dc4e62

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    Network Analysis: A Novel Method for Mapping Neonatal Acute Transport Patterns in California
    (2017) Kunz, Sarah; Zupancic, John; Rigdon, Joseph; Phibbs, Ciaran S.; Lee, Henry C.; Gould, Jeffrey B.; Leskovec, Jure; Profit, Jochen
    Objective: To use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions, and to determine factors associated with transport outside the originating sub-network. Study Design This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically-derived sub-networks were compared to state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression. Results: Empirical sub-networks showed significant overlap with regulatory regions (p <0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (p<0.001), need for surgery (p=0.01), and insurance as the reason for transfer (p<0.001). Conclusion: Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.
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    The Impact of Maternal Characteristics on the Moderately Premature Infant: An Antenatal Maternal Transport Clinical Prediction Rule
    (Nature Publishing Group, 2012) Dukhovny, Dmitry; Dukhovny, Stephanie; Pursley, Dewayne; Escobar, Gabriel J.; McCormick, Marie; Mao, WenYang; Zupancic, John
    Background: Moderately premature infants, defined here as those born between 30 \(\frac{0}{7}\) and 34 \(\frac{6}{7}\) weeks gestation, comprise 3.9% of all births in the United States and 32% of all preterm births. While long-term outcomes for these infants are better than for less mature infants, morbidity and mortality are still substantially increased in comparison to infants born at term. There is an added survival benefit resulting from birth at a tertiary neonatal care center, and although many of these infants require tertiary level care, delivery at lower level hospitals and subsequent neonatal transfer are still common. Objective: Our primary aim was to determine the impact of maternal characteristics and antenatal medical management on the early neonatal course of the moderately premature infant. The secondary aim was to create a clinical prediction rule to determine which infants require intubation and mechanical ventilation in the first 24 hours of life. Such a prediction rule could inform the decision to transfer maternal-fetal patients prior to delivery to a facility with a Level III Neonatal Intensive Care Unit (NICU), where optimal care could be provided without the requirement for a neonatal transfer. Methods: Data for this analysis came from the cohort of infants in the Moderately Premature Infant Project (MPIP) database, a multi-center cohort study of 850 infants born at gestational age 30 \(\frac{0}{7}\) to 34 \(\frac{6}{7}\) weeks, who were discharged home alive. We built a logistic regression model to identify maternal characteristics associated with need for tertiary care, as measured by administration of surfactant. Using statistically significant covariates from this model, we then created a numerical decision rule to predict need for tertiary care. Results: In multivariate modeling, 4 factors were associated with reduction in the need for tertiary care, including, surfactant administration, including non-White race (OR=0.5, [0.3, 0.7], older gestational age, female gender (OR=0.6 [0.4, 0.8]) and use of antenatal corticosteroids (OR=0.5, [0.3, 0.8]). The clinical prediction rule to discriminate between infants who received surfactant, versus those who did not, had an area under the curve of 0.77 [0.73, 0.8]. Conclusions: Four antenatal risk factors are associated with a requirement for Level III NICU care as defined by the need for surfactant administration. Future analyses will examine a broader spectrum of antenatal characteristics and revalidate the prediction rule in an independent cohort.
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    Clinical Benefits, Costs, and Cost-Effectiveness of Neonatal Intensive Care in Mexico
    (Public Library of Science, 2010) Profit, Jochen; Lee, Diana; Zupancic, John; Papile, LuAnn; Gutierrez, Cristina; Goldie, Sue; Gonzalez-Pier, Eduardo; Salomon, Joshua
    Background: Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico. Methods and Findings: A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24–26, 27–29, and 30–33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24–26, 27–29, and 30–33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses. Conclusions: Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis.