Correlation of Neonatal Intensive Care Unit Performance Across Multiple Measures of Quality of Care

Abstract

Objectives To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance. Design We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations. Setting Twenty-two regional NICUs in California. Patients In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007. Main Outcomes Measures Pneumothorax, growth velocity, health care–associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk. Results The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations only 6 were significant (P < .05). Correlations between pairs of quality measures were strong (ρ > .5) for 1 pair, moderate (.3 < |ρ| < .5) for 8 pairs, weak (.1 < |ρ| < .3) for 5 pairs and negligible (|ρ| < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care–associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4. Conclusion In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

Baby-MONITOR: A Composite Indicator of NICU Quality

“…3,4,15 Preliminary steps in the development of the Baby-MONITOR included development of a theoretical framework 4,15 ; expert-informed selection of its measure components 14,16 ; initial data analysis (1) to investigate the completeness of the data, (2) to develop and test adequate measure definitions and restrictions, and (3) to minimize systematic selection and transfer biases; and construction of risk adjustment models. 17 With these building blocks in place, we standardized and risk-adjusted outcomes, weighted the individual components, and aggregated measures to form a composite indicator. After defining a base-case composite, we evaluated its sensitivity to the underlying assumptions and explored the effects of alternative computational approaches.…”

“…Variables included in these models include a combination of prenatal care, gestational age at birth, small for gestational age status, multiple birth, cesarean delivery, inborn or outborn, and 5-minute Apgar score. 17 We used the Draper-Gittoes 21 method of risk adjustment, which has long been used successfully in the UK higher education system. With this method, a standardized z score is constructed that is suitable for combining via unweighted or weighted averaging.…”

“…17,29 In this study, we aggregated the measures, assessed the composite' s ability to discriminate among NICUs, and conducted extensive sensitivity analyses with regard to weighting and aggregation. We found the Baby-MONITOR to be a robust measure and able to discriminate overall quality of care delivery.…”

“…17 Grouping would add to the composite' s complexity and require decisions about weighting within and between subindicators. If replicated in larger datasets we may revise the Baby-MONITOR, but for this initial iteration, we selected a simpler format.…”

Prevention of Nosocomial Infection in the Neurosciences Intensive Care Unit: Remember the Basics

“…The case mix in the neurosciences ICU is not immune to such infectious complications [2,3]. Such infections increase both the costs and lengths of stay [4,5]. Overall mortality rates have progressively improved over the decade, but prevalence remains high despite the advice of the Surviving Sepsis Guidelines [6].…”