Early findings:Regional variation in newborn special care in the U.S.

David C. Goodman, MD MSWade Harrison, MPH

September 2015

Wennberg InternationalCollaborative

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• Over the past 40 years, neonatal intensive care has dramatically reduced newborn mortality and morbidity. (Richardson DK. JAMA. 2001;286:1498-505.)

• In the U.S. success has led to growth in capacity -- the number of Neonatal Intensive Care Units (NICU), NICU beds, and neonatologists -- while the number of live births has changed little. (Goodman, et al. Pediatrics, 2001)

• There is a remarkable degree of regional variation in NICU capacity. And capacity is poorly related to newborn risk or health status or mortality. (Goodman, et al. Pediatrics, 2001) (Goodman, et al. N Engl J Med, 2002)

• At the hospital level, both quality and mortality varies for newborns <1,500 g, even with very careful risk adjustment (Horbar J D et al. Pediatric

Background

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There have been no large population-based studies of newborn cohorts and the use of special (intensive & critical) care.

• Which newborns are admitted to NICUs today, what are their problems, and how much do the admission rates vary across regions and health systems? And what are the causes of the variation?

• Once newborns are admitted to NICUs, what are the care patterns, such as length of stay? And the causes?

• What are the costs of NICU care for different types of patients, and is better care sometimes less intensive and expensive?

Research questions:

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The Epidemiology of Newborn CareThree inter-related projects

• Funders:– Charles H. Hood Foundation

– The State of Texas Medicaid Program

– Anthem Foundation

• Research Team:– Dartmouth Institute (Goodman (PI), Wilkinson, Harrison, Little))

– University of Texas, School of Public Health (Franzini & Ganduglia)

– University of Florida, Institute for Child Health Policy (Shenkam & Delcher)

– State of Texas, Health and Human Services Commission (Ferrara & Blanton)

– State of Texas, Univ. TX Health Science Center, Houston (Tyson)

– Stanford University, School of Medicine (Gould)

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Study populations

Funder Study population Data types Live Births

State of Texas

Texas Medicaid Newborn & maternal claims linked with natality and mortality files

207,000 per yr x 2 years

Anthem Foundation

National commercially insured of one large plan

Newborn & maternal claims

~220,000 per yr x 3 years

Medicaid for selected states

Newborn claims ~1 million per yr x 2 years

Hood Foundation

Nearly entire population of 4 states; BCBS claims of Texas

Newborn claims ~130,000 per yr x 2 years

U.S. birth cohort Linked natality and mortality files

~3.8 million x multiple years

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Today’s study aims

A population-based study of the epidemiology of U.S. NICU admissions using natality files.

1. Describe the risk of NIU admission (level III/IV units) across the entire birth weight spectrum.

1. Describe the characteristics of the cohort of infants admitted to NICUs.

1. Measure trends.

2. Begin descriptions of variation in NICU admissions.

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Study population

• 17,896,048 newborns (2007 – 12) with births recorded using “new” form:73% of U.S. birth cohort during this time– 2007: 22 states and 55% of the total cohort– 2012: 38 states plus D.C. and 88% of the total cohort

• Study Population Characteristics– Newborns: Consistent across years– Maternal: Increasingly older, more highly educated, and Hispanic

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Methods

• Data Sources – 2007-2013 Birth Public Use Natality Files

• Study Population– Live births (>500 g) to U.S. residents (citizen and non-citizen) recorded using

the 2003 birth certificate• Measures

– 1o: NICU admission rates (to units with capability of prolonged ventilation)– 2o: Composition of NICU cohort

• Statistical Analysis– Crude rates and proportions– Modified Poisson regression (trends in admission rates)

• Adjusted for: birth weight, gestational age, weight-for-gestational age, 5-minute Apgar, plurality, delivery mode, sex, parity, race/ethnicity, maternal age and education

– Simple linear regression (trends in the NICU cohort)

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JAMA Pediatrics published online 27 July, 2015

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Level III/IV NICU Admissions by Birth Weight(2012 U.S. Birth Cohort)

Newborns >2,500 g comprise 51.6% of NICU admissions

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Trends in Level III/IV NICU Admission Composition

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Variation in Rates of Admission to Level III/IV NICUs2013 live births > 500 gm

N=3,512,805

Rate of Level III/IV NICU Admissions (%) (2013)N=3.512 million live births (>500 g.)

217 Neonatal Intensive Care Regions

overall rate:7.8%

Unpublished data

Very Low Birth Wt (500-1499 gm) Level III/V NICU Admissions (2013)

N=44,029

Unpublished data

Standardized Rate of Level II/IV NICU Admissions by Birth Weight (2013) (Log scale)

Unpublished data

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A rarely traveled and poorly understood ecosystem

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A rarely studied and poorly understood medical ecosystem