In a recently released article in Pediatrics, Dr. van den Esker-Jonker and colleagues (10.1542/peds.2016-2414) from the Netherlands examine the value of transcutaneous bilirubin (TcB) measurements in decreasing the number of blood draws for serum bilirubin (TSB) measurement among hospitalized jaundiced neonates (ref here). This is a study that makes so much sense, it’s hard to believe that it hasn’t already been done.
Most transcutaneous bilirubinometry studies have included only healthy term infants >35 gestational age, and have not unreasonably focused primarily on the reliability of TcB and its correlation with TSB. The authors of the current study asked if TcB measurements could reduce the number of serum blood draws prior to institution of phototherapy in ill hospitalized infants gestational ages >32 weeks and up – thus expanding the population of interest (as others have begun to do also) and asking a pragmatic study question that impacts the quality of healthcare.
In this interesting study, infants ages 24 hours to < 8 days old and with gestational age 32 weeks and up with clinically observable jaundice were enrolled and randomized to either an experimental or a control group. All infants were treated with phototherapy per the AAP nomogram, but in the experimental group the TcB was used as an aid to avoid blood draws when possible. As safety checks, if the TcB was within 50 micromoles (approximately 3 mg/dL) of the “light level” then a TSB was obtained, and additionally if any attending physician had concerns about an infant, a TSB could be obtained at any time. In the control group infants had TSB obtained per usual and were treated without the benefit of TcB levels.
The authors acknowledge limitations of the study, including a lack of blinding – attending physicians needed to see the infants in order to provide an appropriate safety check for the research – and inability to reach full sample size in one recruitment area. Hopefully you will not mind this spoiler –but the infants in the intervention group had 38.5% fewer blood draws, with no difference in adverse events between groups. The authors point out the great possibilities of transcutaneous bilirubinometry for use in resource-poor settings, as well as its possible expansion to in-hospital settings and ill babies..
This study brought home for me the importance of increasing value in healthcare. Infants in the study benefit by experiencing fewer painful procedures; parents benefit because their infants undergo fewer procedures with less worry waiting for potentially concerning results; and transcutaneous bilirubin checks are less expensive than the cost of a phlebotomist, lab technician and the equipment to safely transport, analyze and then dispose of blood; So although this might seem a small change in practice, it adds up to a large improvement in value.
I visited the AHRQ (Agency for Healthcare Research and Quality) site to learn a bit more about the 6 domains of quality, which include the following aims: the care is safe, effective, patient-centered, timely, efficient and equitable. It certainly appears that this study by Dr. van den Esker-Jonker and colleagues is all about value. While I have barely touched on the study details, I hope you will get a chance to explore them by reading this study yourself.