P2C206: Neonatal Complexity as a Risk Factor for Loss of Follow up in NICU Developmental Clinic

Background: Neonatal follow-up clinics provide neurodevelopmental monitoring for many former premature infants, but a high attrition rate is a well-known limitation for these clinics. Previous studies have assessed maternal risk factors for loss of follow-up, with few focusing on neonatal medical complexity as a potential risk factor. The objective of this study was to examine how neonatal complexity at NICU discharge impacts attendance at NICU follow-up clinic up to 12 months after discharge.

Methods: In a cohort of 444 patients from 2014 to 2017 who were referred to the NICU follow-up clinic at our tertiary center, 266 patients were randomly selected for retrospective chart review. Primary outcome included attendance of NICU follow-up visits throughout a 12-month span. A validated measure for pediatric complexity scoring, the Pediatric Complex Chronic Conditions Classification System version 2, was utilized. It consists of 12 categories including neonatal/prematurity, cardiovascular, neurologic/neuromuscular, renal/urologic, respiratory, gastrointestinal, hematologic/immunologic, malignancy, metabolic, transplantation, technology dependence, and other congenital or genetic defects. Various known maternal psychosocial factors (parity, limited prenatal care, public insurance, and cigarette smoking) previously associated with loss of follow up were controlled for in the multivariate linear regression model.

Results: Sample characteristics were as follows: gestational age less than 37 weeks was 72% (190/262), birth weight (Median= 1532 grams, Interquartile Range (IQR) [995, 2830] grams), length of NICU stay (Median= 43 days, IQR [18, 77] days), and prematurity as the primary referral reason (50% (114/228)). Most patients (67% (166/266)) had 1 to 3 complex chronic conditions (CCC) with the most frequent being 2 CCC (26% (68/266)); neonatal was the most contributory domain (64% (171/266)) followed by cardiovascular (42% (112/266) and neurologic/neuromuscular (29% (77/266)). On average, 84% (221/263) of patients attended their first visit at 6 months, with only 54% (141/263) attending the second visit at 12 months. Patients who attended their first clinic visit had a higher average number of CCC compared than those that did not (mean 2.5 vs 1.9, p = .018). Furthermore, patients with a CCC in the renal domain had a 20% lower follow up rate even after controlling for maternal risk factors (p=.02).

Conclusion: Although neonatal follow-up clinics provide essential neurodevelopmental care for high-risk neonates, neonatal complexity at discharge influenced attendance, with certain domains of CCC being highly associated with loss to follow up. Our results suggest that the CCC measure is a potentially useful tool with which clinicians might prospectively stratify complex neonatal patients’ risk of loss to developmental follow up, and with which researchers might test interventions to improve follow-up retention.