Stead Family Department of Pediatrics, University of Iowa, Iowa City.
Vermont Oxford Network, Burlington.
JAMA Pediatr. 2020 May 1;174(5):e196294. doi: 10.1001/jamapediatrics.2019.6294. Epub 2020 May 4.
The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals.
To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States.
DESIGN, SETTING, AND PARTICIPANTS: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks' 0 days' to 25 weeks' 6 days' gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019.
Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids.
The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months' corrected age and measures of hospital resource use (days of hospitalization and ventilator use).
Among 4176 actively treated infants in the NRN cohort (48% female; mean [SD] gestational age, 24.2 [0.8] weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean [SD] gestational age, 24.2 [0.8] weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean [SD] gestational age, 24.1 [0.8] weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean [SD] gestational age, 24.1 [0.8] weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age-only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%).
An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.
Eunice Kennedy Shriver 国家儿童健康与人类发展研究所新生儿研究网络 (NRN) 极早产结局模型被广泛用于为期待极早产的家庭提供预后。该模型提供了 1998 年至 2003 年的平均结果信息，并未考虑到美国医院之间结局的显著差异。
为美国大多数极早产儿更新和验证 NRN 极早产结局模型。
设计、地点和参与者： 本预后研究纳入了 1998 年 1 月 1 日至 2016 年 12 月 31 日期间来自美国 NRN 的 19 个中心的 3 个观察队列（推导队列）和 Vermont Oxford Network (VON) 的 637 个中心（验证队列）。研究包括 22 周零 0 天至 25 周零 6 天出生、体重 401 至 1000g 的积极治疗婴儿，NRN 中有 4176 例（2006 年至 2012 年），VON 中有 45179 例（2006 年至 2012 年），VON 中有 25969 例（2013 年至 2016 年）。VON 队列包含了超过 85%的美国合格分娩。数据分析于 2017 年 5 月 1 日至 2019 年 3 月 31 日进行。
原始模型中使用的预测变量包括婴儿性别、出生体重、多胎、出生时的胎龄和产前皮质类固醇暴露。
主要结局是出院前死亡。次要结局包括校正后 18 至 26 个月的神经发育障碍以及医院资源使用的测量（住院天数和呼吸机使用）。
在 NRN 队列中的 4176 例积极治疗婴儿中（48%为女性；平均[SD]胎龄为 24.2[0.8]周），生存率为 63%，而原始模型时期（47%为女性；平均[SD]胎龄为 24.2[0.8]周）的 3702 例婴儿中为 62%。在同期（2006-2012 年）的 VON 队列中，45179 例积极治疗婴儿的生存率为 66%（47%为女性；平均[SD]胎龄为 24.1[0.8]周），2013 年至 2016 年的 25969 例婴儿的生存率为 70%（48%为女性；平均[SD]胎龄为 24.1[0.8]周）。2006-2012 年验证队列的模型 C 统计量为 0.74，2013-2016 年验证队列为 0.73。通过使用决策曲线分析将该模型与仅基于胎龄的预后方法进行比较，更新后的模型显示出了预测优势。分娩医院对生存率的预测贡献与胎龄相当（20%），但低于其他因素的总和（60%）。
使用众所周知的因素来预测极早产儿的生存率的更新模型在应用于大型美国队列时表现良好。由于生存率随时间变化，因此模型需要定期更新。分娩医院对结局预测有很大的贡献。
