The Association of Level of Care With NICU Quality

Abstract

Background and Objectives Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; < 1500g) infants. However, a comprehensive assessment of quality of care delivery across different levels of Neonatal Intensive Care Units (NICUs) has not been done. Methods We conducted a cross-sectional analysis of 21,051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 AAP guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines nine risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of zero and a standard deviation of one. Results Wide variation in Baby-MONITOR scores exists across California (mean (SD) 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores. Conclusion The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

Factors Associated With Provider Burnout in the NICU

“…Although it is the most significant risk factor identified in this study, large NICU size is not easily modifiable and may improve quality of patient care, 30,31 highlighting the need for robust vigilance to provider burnout in large, busy NICUs. In addition, burnout recognition education for providers and the implementation of burnout interventions at the individual and institutional level will be crucial, particularly because the current health care trend toward larger centralized units is likely to increase the prevalence of this risk factor.…”

Racial/Ethnic Disparity in NICU Quality of Care Delivery

“…Although the Baby-MONITOR was developed in a rigorous and explicit fashion and has been shown to be robust and able to discriminate overall quality of care among NICUs (8–11, 14, 23, 24), the measure is still in evolution and requires additional validation. Furthermore, this study relied on local abstractors to follow CPQCC standards in retrieving maternal race/ethnicity, and although the CPQCC conducts extensive data training, misclassification cannot be excluded.…”

Survival of Infants Born at Periviable Gestational Ages

“…40,41 However, the level of neonatal care is not necessarily associated with some aspects of quality care, as demonstrated in a recent study of 134 California NICUs. 42 Within limits, greater availability of neonatal intensive care, measured by the number of neonatologists working in a given region, is associated with a decreased neonatal mortality rate. 43 However, the potential benefits of increased availability of neonatal intensive care may be offset by the associated de-regionalization of care that can occur as the number of NICUs increase, with a greater proportion of high-risk births occurring in lower volume centers.…”