772 - Causes of mortality in extremely low gestational age neonates in relation to social determinants of health and over time by comfort care, redirection of care and progressive failure despite support

Publication Number: 2753.772

Nilanjana Banerjee, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States; Anna Reilly, Westchester Medical Center, Briarcliff Manor, NY, United States; Heather Brumberg, New York Medical College, Maria Fareri Children's Hospital at Westchester Medical Center, Valhalla, NY, United States; Edmund F.. La Gamma, New York Medical College, Valhalla, NY, United States

Background: Extremely low gestational age neonate(ELGAN) mortality decreased with active treatment. Previous work focused on a binary(yes/no) approach to active support or clinical conditions related to death. Little is known regarding reasons for death in relation to clinician predilection of active support vs. comfort care over time or by demographics.

Objective: To determine whether differences exist in categories of comfort care, redirection of care, or progressive failure despite support by gestational age, over time, race, ethnicity, insurance status or inborn(IB)/outborn(OB) status for ELGANs(22-28 wks) who expired.

Design/Methods: This was a retrospective study(2006-2024) of ELGANs born at(IB) or transferred to(OtB) Maria Fareri Children's Hospital(MFCH, Level IV NICU) & subsequently died using perinatal database data(PD). The outcome was causes of death which including 1) No support, poor prognosis, 2) No support, lethal anomaly, 3) Support withdrawn, lethal anomaly, 4) Support withdrawn, poor neuro prognosis & 5) Progressive failure despite support. These were compared by gestational categories(22-24 wks vs. 25-28 wks), epochs[(2006-2012), (2013-2019) & (2020-2024) throughout stable NICU faculty] & IB vs. OtB status. Race(Black vs. White), ethnicity(Hispanic vs. Non-Hispanic) & insurance(Medicaid vs. private insurance) subgroups were analyzed for IB infants whose birth certificates were available to merge with PD. Analysis used χ2/Fisher's & Cochran-Armitage (trend over time).

Results: 405 ELGANs died at MFCH(2006-2024). 81% (328/405) were IB & 19% (77/405)OtB. Over time, no support, poor prognosis, decreased significantly for the 22-24 week gestational age category(Table 1). Concurrently, progressive failure despite support increased for this group, but this was not significant. Progressive failure despite support was also more frequent in OtB compared with IB 22-24 gestation age group(Table 2). Of IBs, race, ethnicity & insurance did not differ by cause of death(Table 3).

Conclusion(s): We found, of IB ELGANs, social determinants of health (race, ethnicity, insurance) did not impact cause of death. The 22-24 wks group had a decline in deaths attributed to lack of support for poor prognosis by epochs, suggesting increasing provision of active treatment at the lowest gestations. The same gestational age category had higher progressive failure despite support in the OtBs. We speculate this indicates a reluctance in community hospitals to redirect comfort care. Our results suggest clinicians may consider earlier discussion of redirection of care to prevent futile interventions.

Table 1
Cause of death among epochs in inborn infants with gestational age of 22-24 weeks and 25-28 weeks

Table 2
Cause of death among inborn and outborn infants with gestational age of 22-24 weeks and 25-28 weeks

Table 3
Cause of death in inborn infants with gestational age of 22-24 weeks and 25-28 weeks stratified by race, ethnicity and insurance status