Estimated Survival and Major Comorbidities of Very Preterm Infants Discharged Against Medical Advice vs Treated With Intensive Care in China
Siyuan Jiang, Xiangyuan Huang, Lan Zhang, Junyan Han, Yi Yang, Weiping Wang, Shoo K. Lee, Weili Yan, Yun Cao, Reduction of Infection in Neonatal Intensive Care Units Using the Evidence-Based Practice for Improving Quality (REIN-EPIQ) Study Group, Yun Cao, Siyuan Jiang, Yong Bae Ji, Shuping Han, Sannan Wang, Zhankui Li, Shiwen Xia, Changyi Yang, Chuanzhong Yang, Ling Chen, Ruobing Shan, Ling Liu, Bin Yi, Yang Wang, Jiang-Qin Liu, Ling He, Mingxia Li, Xinnian Pan, Yan Guo, Cui-qing Liu, Qin Zhou, Xiaoying Li, Hong Xiong, Yujie Qi, Mingyan Hei, Yong Han, Shuping Wang, Sannan Li, Zhankui Xia, Shiwen Yang, Chuanzhong Lin, Zhenlang Chen, Ling Shan, Ruobing Liu, Ling Yi, Bin Wang, Yang Liu, Jiangqin He, Ling Li, Mingxia Pan, Xinnian Guo, Yan Liu, Cuiqing Zhou, Qin Li, Xiong Xiaoying, Hong Qi, Yujie Hei
Abstract
Importance: A significant proportion of very preterm infants (<32 weeks' gestation) are discharged against medical advice (DAMA) from neonatal intensive care units in China. There is minimal information available on the potential outcomes of providing complete care before discharge in these infants. Objective: To describe potential neonatal outcomes of DAMA in very preterm infants if they receive complete care based on estimates derived from a group of propensity score-matched infants who are not DAMA. Design, Setting, and Participants: This cohort study enrolled all infants born at between 24 and 31 weeks' gestation from May 1, 2015, to April 30, 2018, and admitted to 25 tertiary neonatal intensive care units across China within 7 days of birth. A multilevel mixed-effects logistic regression model was constructed to estimate the propensity score for the likelihood of DAMA for each infant. Infants who were not DAMA were then matched to DAMA infants with the closest propensity score on a 1:1 ratio by using a nearest neighbor greedy matching algorithm without replacement. Incidences of neonatal outcomes were then calculated among the matched non-DAMA infants to simulate the outcomes of DAMA infants. Statistical analyses were performed from August 16, 2020, to September 26, 2020. Exposures: Discharge against medical advice, which was defined as termination of treatment and discharge before the treating physicians recommended discharge. Main Outcomes and Measures: Survival and survival without major morbidity. Results: The study enrolled a total of 14 083 infants (8141 boys [57.8%]) with a median gestational age of 30.1 weeks (interquartile range [IQR], 29.0-31.1 weeks) and a median birth weight of 1400 g (IQR, 1170-1600 g). Overall, 1876 of 14 083 very preterm infants (13.3%; 95% CI, 12.8%-13.9%) were DAMA, of whom 1367 of 1876 (72.9%; 95% CI, 70.8%-74.8%) required intensive care on discharge. A total of 1473 DAMA infants were successfully matched to 1473 non-DAMA infants. Overall, 1211 of 1473 matched non-DAMA infants (82.2%; 95% CI, 80.2%-84.1%) survived to discharge. The survival rates were 68.3% (95% CI, 62.4%-73.7%) for infants at 26 to 27 weeks' gestation, 84.1% (95% CI, 80.7%-87.0%) for infants 28 to 29 weeks' gestation, and 92.4% (95% CI, 90.0%-94.2%) for infants at 30 to 31 weeks' gestation. A total of 872 of 1473 matched non-DAMA infants (59.2%; 95% CI, 56.7%-61.7%) survived without any major morbidity. Conclusions and Relevance: The results of this cohort study suggest that very preterm infants who are DAMA from neonatal intensive care units may have intact survival if complete care is provided. Efforts to reduce DAMA may be associated with improved outcomes of very preterm infants in China.