Consultative Service Utilization Around Periviable Deliveries

INTRODUCTION Multiple factors play important roles in decision-making regarding delivery room resuscitation in periviable infants. Studies have shown that practice variability exists between neonatologists and maternal fetal medicine specialists with respect to how periviable antenatal consultations are conducted. However, there is no data to date reporting utilization of other consultative services, or provider billing practices around periviable deliveries. METHODS: Inborn periviable births in 2013-2015 at 6 centers were reviewed retrospectively. Mothers/babies admitted with living fetuses for unplanned periviable delivery and born at 22 0/7 to 24 6/7 weeks gestational age (GA) were studied unless there were major congenital anomalies, life-limiting genetic conditions, fetal demise soon after admission, or missing data. RESULTS: A total of 305 periviable deliveries (350 babies) were analyzed of which 43 were products of twin and 2 triplet gestation. GA at delivery were: 22 weeks (21%), 23 weeks (32%) and 24 weeks (47%). A social worker (SW) and/or chaplain (CH) was involved in 78% and 31% of births respectively, overall consultative services were involved in 87% (265/305) of deliveries. Involvement was significantly lower before delivery (SW: 21% vs. 74%, p= 0.000; CH: 10% vs 25%, p=0.000) and were more likely to be involved after death, irrespective of GA (table 1). Caucasian mothers were less likely to receive SW consults (72% vs 82%, p=0.05) and more likely to have CH visits (39% vs 26%, p=0.02) as compared to African American mothers. A single mother without family support was least likely to receive a SW consult (p=0.005) (table 2). Fifty-five percent (90/164) of the initial neonatology consults were not billed. Despite attendance at delivery, 22% (53/248) of the deliveries attended were not billed by a neonatologist or NNP. Comfort care (CC) after delivery was provided in 38% (30/79) of patients and no provider billing was documented for 43% (13/30) of those patients that received CC in any location. Median time for CC in Labor and Delivery unit was 0.7 hours (IQR: 0-3) and 1.2 hours (IQR: 0.8-1.5) for those admitted to NICU. DISCUSSION: Decision making around periviable delivery can be both ethically challenging and morally distressing. Arriving at such a decision through an interdisciplinary, family centered team approach can minimize suffering of both babies and their parents. Our data suggests our consultative services are often reactionary, giving support after birth and/or death, instead of preemptive during the decision-making period. Institutional variability may account for racial/parenting disparity in SW and CH visits, however this will be further explored Billing practices varied significantly between institutions in this cohort. Not billing for services provided may be equally as inappropriate as billing for a service not provided. Future work will attempt to evaluate billing practices and rationale in more detail.