The heterogeneous causal effects of neonatal care: a model of endogenous demand for multiple treatment options based on geographical access to care

Abstract

Neonatal units in the UK are organised into three levels, from highest Neonatal Intensive Care Unit (NICU), to Local Neonatal Unit (LNU) to lowest Special Care Unit (SCU). We model the endogenous treatment selection of neonatal care unit of birth to estimate the average and marginal treatment effects of different neonatal designations on infant mortality, length of stay and hospital costs. We use prognostic factors, survival and hospital care use data on all preterm births in England for 2014-2015, supplemented by national reimbursement tariffs and instrumental variables of travel time from a geographic information system. The data were consistent with a model of demand for preterm birth care driven by physical access. In-hospital mortality of infants born before 32 weeks was 8.5% overall, and 1.2 (95% CI: −0.7, 3.2) percentage points lower for live births in hospitals with NICU or SCU compared to those with an LNU according to instrumental variable estimates. We find imprecise differences in average total hospital costs by unit designation, with positive unobserved selection of those with higher unexplained absolute and incremental costs into NICU. Our results suggest a limited scope for improvement in infant mortality by increasing in-utero transfers based on unit designation alone.

Development of capability lists for neonatal critical care at three levels in China: a modified Delphi study

“… 16 In BAPM’s opinion, newborns delivered at <27 weeks of gestational age require complex and long-term intensive care, and should be transferred to the nearest NICU. 23 …”

“…Special and intensive care is centralised in hospitals of designated levels. 23 WHO indicates that inpatient interventions are proven to be effective in preventing neonatal mortality and disability, according to different health system levels. Special and intensive care is required based on well-established obstetric care and basic neonatal care.…”

“…16 In BAPM's opinion, newborns delivered at <27 weeks of gestational age require complex and long-term intensive care, and should be transferred to the nearest NICU. 23 In this study, neonatal care is stratified by gestational age and birth weight. County-level centres should provide CPAP ≥72 hours and conventional ventilation ≥24 hours; city-level and province-level centres should provide these two techniques routinely and continuously and provincelevel centres are expected to perform high-frequency ventilation.…”