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OBJECTIVE: Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born. DESIGN: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level). RESULTS: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns. CONCLUSIONS: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed. [ABSTRACT FROM AUTHOR]

Objectives: To examine changes in care practices over time by race and ethnicity and whether the decrease in hospital mortality and severe morbidities has benefited infants of minority over infants of white mothers., Methods: Infants 22 to 29 weeks' gestation born between January 2006 and December 2017 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals for African American and Hispanic versus white infants by birth year. We tested temporal differences in mortality and morbidity rates between white and African American or Hispanic infants using a likelihood ratio test on nested binomial regression models., Results: Disparities for certain care practices such as antenatal corticosteroids and for some in-hospital outcomes have narrowed over time for minority infants. Compared with white infants, African American infants had a faster decline for mortality, hypothermia, necrotizing enterocolitis, and late-onset sepsis, whereas Hispanic infants had a faster decline for mortality, respiratory distress syndrome, and pneumothorax. Other morbidities showed a constant rate difference between African American and Hispanic versus white infants over time. Despite the improvements, outcomes including hypothermia, mortality, necrotizing enterocolitis, late-onset sepsis, and severe intraventricular hemorrhage remained elevated by the end of the study period, especially among African American infants., Conclusions: Racial and ethnic disparities in vital care practices and certain outcomes have decreased. That the quality deficit among minority infants occurred for several care practice measures and potentially modifiable outcomes suggests a critical role for quality improvement initiatives tailored for minority-serving hospitals., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking., Methods: Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs., Results: We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents., Conclusions: Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background: NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs., Methods: Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t -test comparison of quartiles, univariable regression, and multivariable regression., Results: Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence., Conclusions: Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Background: Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of 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 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1., 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., Conclusions: 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., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: We sought to describe the current costs of newborn care by using population-based data, which includes linked vital statistics and hospital records for both mothers and infants. These data allow costs to be reported by episode of care (birth), instead of by hospitalization., Methods: Data for this study were obtained from the linked 2000 California birth cohort data. These data (n = 518,704), provided by the California Office of Statewide Health Planning and Development (OSHPD), contain infant vital statistics data (birth and death certificate data) linked to infant and maternal hospital discharge summaries. In addition to the infant and maternal hospital discharge summaries associated with delivery, these data include discharge summaries for all infant hospital-to-hospital transfers and maternal prenatal hospitalizations. The linkage algorithm that is used by OSHPD in creating the linked cohort data file is highly accurate. More than 99% of the maternal and infant discharge abstracts were linked successfully with the birth certificates. These data were also linked successfully with the infant discharge abstracts from the receiving hospital for 99% of the infants who were transferred to another hospital. The hospital discharge records were the source of the hospital charges and length-of-stay information summarized in this study. Hospital costs were estimated by adjusting charges by hospital-specific ratios of costs to charges obtained from the OSHPD Hospital Financial Reporting data. Costs, lengths of stay, and mortality were summarized by birth weight groups, gestational age, cost categories, and types of admissions., Results: Low birth weight (LBW) and very low birth weight (VLBW) infants had significantly longer hospital stays and accounted for a significantly higher proportion of total hospital costs. The average hospital stay for LBW infants ranged from 6.2 to 68.1 days, whereas the average hospital stay for infants who weighed >2500 g at birth was 2.3 days. Overall, VLBW infants accounted for 0.9% of cases but 35.7% of costs, whereas LBW infants accounted for 5.9% of cases but 56.6% of total hospital costs. Although total maternal and infant costs were similar (approximately 1.6 billion dollars), the distribution of maternal costs was much less skewed. For infants, 5% of infants accounted for 76% of total infant hospital costs. Conversely, the most expensive 3% of deliveries accounted for only 17% of total maternal costs., Conclusions: The very smallest infants make up a hugely disproportionate share of costs; more than half of all neonatal costs are incurred by LBW or premature infants. Maternal costs are similar in magnitude to newborn costs, but they are much less skewed than for infants. Preventing premature deliveries could yield very large cost savings, in addition to saving lives.

Objective: In 1976, the Committee on Perinatal Health recommended that hospitals with no neonatal intensive care unit (NICU) or intermediate NICUs transfer high-risk mothers and infants that weigh <2000 g to a regional NICU. This standard was based on expert opinion and has not been validated carefully. This study evaluated the effect of NICU level and patient volume at the hospital of birth on neonatal mortality of infants with a birth weight (BW) of <2000 g., Methods: Birth certificates of 16 732 singleton infants who had a BW of <2000 g and were born in nonfederal hospitals in California in 1992 and 1993 were linked to death certificates and to discharge abstracts. The hospitals were classified by the level of NICU: no NICU, no intensive care; intermediate NICU, intermediate intensive care; community NICU, expanded intermediate intensive care; and regional NICU, tertiary intensive care. A logistic regression model that controlled for demographic risks, diagnoses, transfer, average NICU census, and NICU level was estimated using death within the first 28 days or first year of life if continuously hospitalized as the main outcome measure., Results: Compared with birth in a hospital with a regional NICU, risk-adjusted mortality of infants with BW of <2000 g was higher when birth occurred in hospitals with no NICU (odds ratio [OR]: 2.38; 95% confidence interval [CI]: 1.81-3.13), an intermediate NICU (OR: 1.92; 95% CI: 1.44-2.54), or a small (average census <15) community NICU (OR: 1.42; 95% CI: 1.14-1.76). Risk-adjusted mortality for infants who were born in hospitals with a large (average census > or =15) community NICU was not statistically different compared with those with a regional NICU (OR: 1.11; 95% CI: 0.87-1.43). Except for large community NICUs, all of these ORs are larger when the data are restricted to infants with BW of <1500 g or BW of <1250 g and smaller for BW between 1250 g and 1999 g and 1500 g and 1999 g. For large community NICUs, the results are similar for the smaller BW intervals and significant only for the larger BW interval., Conclusions: These results support the recommendation that hospitals with no NICU or intermediate NICUs transfer high-risk mothers with estimated fetal weight of <2000 g to a regional NICU. For infants with BW of <2000 g, birth at a hospital with a regional NICU is associated with a lower risk-adjusted mortality than birth at a hospital with no NICU, intermediate NICU of any size, or small community NICU. Subsequent neonatal transfer to a regional NICU only marginally decreases the disadvantage of birth at these hospitals. The evidence for the few hospitals with large community NICUs is mixed. Although the data point to higher mortality in large community NICUs, they are not conclusive and additional study is needed on the mortality effects of large community NICUs. Greater efforts should be made to deliver infants with expected BW of <2000 g at hospitals with regional NICUs.

Objectives: To estimate excess direct medical costs of low birth weight from maternal smoking and short-term cost savings from smoking cessation programs before or during the first trimester of pregnancy., Methods: Simulations using data on neonatal costs per live birth. Outcome measures are mean US excess direct medical cost per live birth, total excess direct medical cost, reductions in low birth weight, and savings in medical costs from an annual 1 percentage point drop in smoking prevalence among pregnant women., Results: Mean average excess direct medical cost per live birth for each pregnant smoker (in 1995 dollars) was $511; total cost was $263 million. An annual drop of 1 percentage point in smoking prevalence would prevent 1300 low birth weight live births and save $21 million in direct medical costs in the first year of the program; it would prevent 57,200 low birth weight infants and save $572 million in direct medical costs in 7 years., Conclusions: Smoking cessation before the end of the first trimester produces significant cost savings from the prevention of low birth weight.

Background: Low birth weight is a major determinant of neonatal mortality. Yet birth weight, even in conjunction with other demographic markers, is inadequate to explain the large variations in neonatal mortality between intensive care units. This variation probably reflects differences in admission severity. The authors have recently developed the Score for Neonatal Acute Physiology (SNAP), an illness severity index specific for neonatal intensive care, and demonstrated illness severity to be a major determinant of neonatal mortality., Objective: To define the relative contributions of birth weight and illness severity to the risk of neonatal mortality and to identify other significant independent risk factors., Methods: Logistic regression was used to analyze data from a cohort of 1621 consecutive admissions to three neonatal intensive care units (92 deaths), to test six alternative predictive models. The best logistic model was then used to develop a simple additive clinical score, the SNAP Perinatal Extension (SNAP-PE)., Results: These analyses demonstrated that birth weight and illness severity are powerful independent predictors across a broad range of birth weights and that their effects are additive. Below 750 g, there is an interaction between birth weight and SNAP. Other factors that showed independent predictive power were low Apgar score at 5 minutes and small size for gestational age. Separate derivation and test samples were used to demonstrate that the SNAP-PE is comparable to the best logistic model and has a sensitivity and specificity superior to either birth weight or SNAP alone (receiver-operator characteristic area .92 +/- .02) as well as excellent goodness of fit., Conclusion: This simplified clinical score provides accurate mortality risk estimates for application in a broad array of clinical and research settings.

Many neonates are referred to neonatal intensive care units (NICUs) for specialized care far from their parents' residence. This distance can add to the stress of the parents and reduce the contact of the parents with their newborn. Small studies have found that back transporting these neonates to hospitals closer to their homes is safe and cost-effective. Despite these findings, the reluctance of many insurers to pay for back transports prevents or delays many back transports. Insurers may not consider the findings of the previous studies to be conclusive, given that the comparisons were between small numbers of neonates back transported and neonates who remained in tertiary care, and the potential for differences in severity of illness between the groups is significant. In this study the effect on hospital charges of back transports was examined by comparing the charges for care in community hospitals with what these charges would have been in a tertiary care center. The advantage of this method is that it avoids case-mix differences between the groups and thus minimizes the potential for small-sample bias. Data were collected for all back transports from a NICU to non-tertiary care centers (n = 90) for a 9-month period. We were able to obtain the itemized bills for the care at community hospitals for 42 of these patients. Each bill was recalculated using the charges for the NICU to determine potential for savings. The average charges for recovery care were about $6200 lower at the community hospital than they would have been at the NICU.(ABSTRACT TRUNCATED AT 250 WORDS)

EXOSURF is a protein-free surfactant composed of 85% dipalmitoylphosphatidylcholine, 9% hexadecanol, and 6% tyloxapol by weight. A single dose of 5 mL of EXOSURF per kilogram body weight, which gave 67 mg of dipalmitoylphosphatidylcholine per kilogram body weight, or 5 mL/kg air was given intratracheally in each of two controlled trials: at birth to neonates 700 through 1350 g (the prophylactic trial, n = 74) or at 4 to 24 hours after birth to neonates greater than 650 g who had hyaline membrane disease severe enough to require mechanical ventilation (the rescue trial, n = 104). In both studies, time-averaged inspired oxygen concentrations and mean airway pressures during the 72 hours after entry decreased significantly (P less than .05) in the treated neonates when compared with control neonates. Thirty-six percent of the treated neonates in the rescue study had an incomplete response to treatment or relapsed within 24 hours, suggesting the need for retreatment in some neonates. In the rescue trial, risk-adjusted survival increased significantly in the treated group. There were no significant differences in intracranial hemorrhages, chronic lung disease, or symptomatic patent ductus arteriosus between control and treated infants in either trial.

To understand the sources of the high costs of neonatal intensive care, financial and medical information on 1,185 admissions to an intensive care nursery was gathered. Multiple regression analysis showed that a significant portion of the variation in individual costs was explained by three measures of risk: low birth weight, surgical intervention, and assisted ventilation. There was a highly skewed distribution of costs. Nearly half of all admissions had none of the above risk factors, had an average cost of about $2,000, and accounted for only 13% of the total costs for the whole sample. In contrast, less than one quarter of the admissions had two or more of the risk factors, had an average cost of $19,800, and accounted for nearly 60% of the total costs. Models that predict costs and length of stay on a basis of seven risk factors were developed to allow for differences in patient populations.

Clinical and billing data were collected on all admissions to six California newborn intensive care units during a 6-month period. Charges were adjusted to costs using Medicaid cost to charge ratios and for inflation, and patients were classified by the diagnosis-related group (DRG) system. Costs were from 97% to 708% more than the proposed DRG reimbursement levels. Regression analysis showed that DRGs explained 22% of the variation in costs. An alternative model using binary variables to control for birth weight, assisted ventilation, surgery, survival, multiple births, and mode of discharge explained 42% of the variation in costs. In contrast to other proposed DRG alternatives, this simple model does not require special training or subjective decision-making.