Synopsis: Neonatal mortality rates are significantly lower in hospitals that have in-house neonatal intensive care units with high daily NICU census.
Source: Phibbs CS, et al. The effects of patient volume and level of care at the hospital of birth on neonatal mortality. JAMA 1996;276:1054-1059.
Phibbs et al performed a retrospective analysis of 53,229 infants classified as likely neonatal intensive care unit (NICU) patients in whom birth certificate data were linked to discharge abstracts and infant death certificates. Reduced risk-adjusted neonatal mortality rates were significantly related to the average daily NICU census and the level of NICU care at the hospital of birth.
COMMENT BY RICHARD EHRENKRANZ, MD, FAAP
The number of Level II and Level II+ NICUs has increased during the past 10-15 years in response to a number of factors, including an increase in the availability of trained neonatologists and the development of therapies such as surfactant treatment of RDS. All have had marked effects upon the management of high-risk infants and the decision by hospitals to build NICUs to attract obstetrical patients or in response to pressure exerted by obstetricians. This report presents a retrospective analysis of neonatal mortality in a subset of singleton infants, now children, born in California in 1990 with conditions that were likely to result in an NICU admission. This report is important because the authors demonstrate that the trend toward de-regionalization of perinatal-neonatal care has been associated with an adverse effect on neonatal mortality. Specifically, NICU patient value and NICU level were each found to have "significant effects on risk-adjusted neonatal mortality." After controlling for other variables, "infants born at hospitals with an average daily NICU census of at least 20 patients/day had significantly lower risk-adjusted morality than those born in hospitals without an NICU." If the level of NICU were considered without controlling for average daily census, infants born at hospitals with level II and level II+ units had similar mortality to those born at level I hospitals, and infants born at hospitals with level III NICUs had the lowest risk-adjusted mortality.
In addition, transferred infants had a significantly higher mortality rate when compared to infants who were not transferred for higher levels of NICU care. Finally, risk-adjusted costs and length of stay were found to be virtually the same between hospitals with large level III NICUs and all other hospitals with NICUs. The authors conclude that neonatal mortality will be decreased without any increase in costs if high-risk deliveries are concentrated in hospitals with large level III NICUs. Physicians and managed care organizations should take note of these findings and support a return to regionalized care for high-risk deliveries. (Interested readers are referred to: Toward Improving the Outcome of Pregnancy: The ’90s and Beyond. March of Dimes Birth Defects Foundation, 1993).
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