Learned lessons, changing practice and cutting-edge research: how to reduce scientific uncertainty in neonatology pursuing the triple aim

Without research there is no hope.

Paul G. Rogers, “Mr Health” of the U.S. Congress (1921–2008)

Despite some concerns about the utility of medical conferences [1], we are convicted that medical congresses are useful tools for promoting the meeting of scientists and researchers from various countries, especially to share their experiences and to present preliminary results on advanced researches. This is of considerable importance when an international conference is organized by the cooperation of professional societies from different medical areas, encouraging the participation of physicians and researchers with different medical specialties. Following our recent tradition, we are pleased to announce the ninth edition of the International Workshop on Neonatology, a multidisciplinary “forum” taking place every year in Cagliari, Italy, with the participation of scientists and opinion leaders belonging to neonatology, pediatrics, laboratory medicine, and to other medical specialties closely related with neonatal care. In the era of healthcare crisis and cost containment, we are pursuing the idea to invest time and money to joint competences, experiences, and results in order to improve the quality of neonatal care and to reduce the morbidity and the mortality rates of babies.

This year, the conference will be opened by the President of the Italian National Committee for UNICEF, with the intent to highlight the importance of reducing disparities among populations. In 2000, the UN Millennium Declaration was signed by 189 countries, and translated into eight Millennium Development Goals (MDGs) for development and poverty eradication. These goals are supposed to be achieved by 2015. MDG-4 (reducing child mortality) together with MDG-5 (improving maternal health) and MDG-6 (Combating HIV/AIDS, malaria, and other diseases) are directly related to health. Part of the challenge is to get more existing knowledge into practice, improving health outcomes; however, a stronger body of knowledge about which system strengthening strategies are effective, and which are not, has been also identified as key factor [2]. Thus, not surprisingly, our conference aims to get the newest frontiers in translational researches with special contributions in the field of prenatal screening, omics, nutrition, pharmacology, etc. One of the most important objectives is to reduce the so-called “scientific uncertainty” which is a factor giving rise to unnecessary costs in health care and no additional improvement to patients outcome. A significant contribution to the achievement of this objective is the close cooperation between neonatology, intensive care medicine, and laboratory medicine. For example, the goal of neonatal intensive care is survival without unacceptable severe morbidity. Taking into account the increasing rate of preterm births worldwide, this goal seems hard to achieve [3]. Major neonatal morbidity, such as prolonged asphyxia, septic shock, periventricular leukomalacia, severe degrees of intraventricular hemorrhage, retinopathy of prematurity, and bronchopulmonary dysplasia, are of significant concern because they are associated with an increased risk for poor long-term outcome [4,5]. Knowledge in biochemical pathways involved in the development of these processes as well as reliable data on sensitivity, specificity, predictive positive- and negative value, etc., of candidate surrogate biomarkers represent a fundamental contribution to avoid the scientific uncertainty. New perspectives for neonatal care improvement seem to be opened by the growth of the fetal laboratory medicine [6]. As recently stated, “fetal laboratory medicine offers a pioneer opportunity for diagnostic testing, forging the frontier of maternal-fetal medicine” [7]. The discovery of fetal cell-free nucleic acids in plasma of pregnant women has led to the development of noninvasive technologies for antenatal diagnosis of fetal aneuploidy [8]. Fetal DNA is detectable as early as day 18 after embryo transfer in cases of assisted reproduction. Advantages of very early detection, without the possibility of procedure-related loss of an unaffected fetus, hold great promise [9]. Prenatal endocrine analysis is another area of fetal diagnostic impact. The goal of prenatal diagnosis and treatment of 21-OH deficiency, originating congenital adrenal hyperplasias, is prevention of prenatal virilization in affected female fetuses, and avoidance of consequences such as risk of gender misassignment, gender confusion, and indications for possible corrective genital surgery [10]. Early diagnosis, preferably before the 15th gestational week, is desirable. Fetal laboratory measurements may potentially offer prognostic information regarding postnatal organ function and may be helpful for clinical decision-making regarding timing of delivery. The rapid progress in the application of metabolomics for clinical purposes seems to be an extraordinary, promising tool for perinatal medicine [11]. In particular, metabolomics in fetal-maternal medicine may open new therapeutic possibilities for preventing late-onset diseases [12]. For example, lower plasma betaine and trimethylamine-N-oxide concentrations were observed in maternal plasma in case of fetal malformation. Additional different significant findings were reported for amino acids involved in gluconeogenesis, for cis-aconitate, acetone, 3-hydroxybutyrric, and hypoxanthine. These data suggest that the malformed fetuses demand enhanced gluconeogenesis and tricarboxylic acids cycle (Krebs Cycle), possibly due to hypoxic metabolism. Significant differences were observed also between normal pregnancies and those developing later gestational diabetes.

Finally, in the course of our conference we aim to revitalize the debate on how to allocate funds for the research in the era of financial crisis and austerity. Two issues should be preliminarily considered: (a) the reduction of health care costs should drain at least a portion of saved money to research founds; (b) incentives should be distribute to whom has obtained valuable experimental results with a rapid translation from bench to bedside for adding value in healthcare. According to a report published in 2012 by the Institute of Medicine (IOM), every year, a massive amount in money is spent for unnecessary health care costs; for example, the United States spends eight times as much money as the Pentagon spent for each year of its operations in Iraq. Factors that give rise to unnecessary costs include scientific uncertainty; perverse economic and practice incentives; system fragmentation; opacity as to cost, quality, and outcomes; changes in the population’s health status; lack of patient engagement in decisions; excess administrative costs; and underinvestment in population health. The reduction of these unnecessary costs may be an optimal source of funding for medical research. How is it possible to reduce these costs? An encouraging example is pursuing the so-called “triple aim”. Originally developed by the Institute for Healthcare Improvement (IHI), the Triple Aim is a framework that describes an approach to optimizing health system performance [13]. The Triple Aim emphasizes three goals [14]. The first is to improve the overall health of the population being served, which requires that providers define the population and then acquire a better understanding of the health status of this population. In neonatology, we could identify several populations: critically ill newborns in intensive care unit (ICU); babies and children born in India, Nigeria, Democratic Republic of the Congo, Pakistan and China (the five countries where about half of under-five deaths occur); etc. Such stratification helps identify which patients require special services, such as complex care management or coordination of services, activities that have traditionally been provided by health plans but will likely shift back to the provider community as providers begin to share risk with payers. The second goal of the triple aim is to deliver not just the right type of care, but actually improve the care experience. Although this will be influenced by the service levels provided across the continuum of care, the patient-centered medical home (PCMH) will play a critical role by providing each patient access to a personal provider and care team responsible for coordinating their care by uniting teams of medical professionals that can address all of a patient’s medical and behavioral healthcare needs. The third objective of the Triple Aim is to provide the best care possible while flattening or lowering the per capita costs of care over time. Pursuing these three objectives at once allows healthcare organizations to identify and fix problems such as poor coordination of care and overuse of medical services. It also helps them focus attention on and redirect resources to activities that have the greatest impact on health. Very few experiences have been reported in the literature on the application of triple aim to pediatric and neonatal care [15]; it is obvious that physicians and their practices need specific guidance and support to achieve the practice transformation that is necessary and desired to achieve the triple aim goal. However, our ambition is to apply advances in research for pursuing better care at lower cost and our conference may become a reference for starting this journey.

The Journal of Maternal-Fetal & Neonatal Medicine is pleased to collaborate with the article authors in the preparation of this supplement, which has been supported by a grant from A. De Mori Radiometer, Siemens Healthcare.

Declaration of Interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.