Underuse Versus Overuse of Neonatal Intensive Care: What Is the Right Amount?

Abstract

See related article, p 73 See related article, p 73 The landscape of neonatal care has changed significantly over the past several decades, with the evolution of acute care regionalization in an effort to optimize resource use and provide high-quality risk-appropriate care to both mothers and their infants.1Lorch S.A. Myers S. Carr B. The regionalization of pediatric health care.Pediatrics. 2010; 126: 1182-1190Crossref PubMed Scopus (103) Google Scholar Ongoing challenges include disparities in timely access to obstetric and neonatal care, regional and interhospital variation in where and how high-risk infants are cared for, and postnatal transport of acutely ill neonates. Based on population-based studies demonstrating decreased mortality rates among very low birth weight infants delivered at higher levels of neonatal care, the American Academy of Pediatrics has published clear definitions of levels of neonatal care, recommending that infants <32 weeks of gestation or <1500 grams (very low birthweight [VLBW]) be delivered at level III neonatal intensive care units (NICUs).2Lasswell S.M. Barfield W.D. Rochat R.W. Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis.JAMA. 2010; 304: 992-1000Crossref PubMed Scopus (252) Google Scholar, 3American Academy of Pediatrics Committee on Fetus and Newborn Levels of neonatal care.Pediatrics. 2012; 130: 587-597Crossref PubMed Scopus (425) Google Scholar Despite this robust evidence, there is continued regional variation across the US in the delivery location of these highest risk infants.4Rysavy M.A. Li L. Bell E.F. Das A. Hintz S.R. Stoll B.J. et al.Between-hospital variation in treatment and outcomes in extremely preterm infants.N Engl J Med. 2015; 372: 1801-1811Crossref PubMed Scopus (435) Google Scholar In contrast, less is known about where moderately and late preterm infants should receive their neonatal care. Although there is a large body of evidence highlighting the increased risk for adverse short-term and long-term outcomes of these infants compared with their term counterparts, albeit to a lesser degree than the very preterm population, studies demonstrating associations between level of neonatal care received and outcomes are lacking. In this volume of The Journal, Harrison et al report an investigation of the variation in NICU admissions across the US in 2013 by birthweight categories and conclude that there is underuse of NICU care for infants ≤1500 grams and potentially overuse of NICU care for larger infants ≥2500 grams.5Harrison W.N. Wasserman J.R. Goodman D.C. Regional variation in neonatal intensive care admissions and the relationship to bed supply.J Pediatr. 2017; 192: 73-79Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar This unique study is the first to evaluate the regional variation of neonatal admissions across the entire US birth cohort and does so by assigning newborns and NICU beds to neonatal intensive care regions. Their findings reveal that after adjusting for maternal and infant characteristics, regions with higher bed supply were associated with an increased risk of admission for infants ≥2500 grams. In contrast, bed supply was not associated with neonatal admissions for VLBW infants despite bed availability. The take-home message from this rigorous study seems to be that although NICU bed supply is not driving NICU admissions for VLBW infants, there are still significant numbers of VLBW infants not receiving appropriate specialized care. In addition, for larger infants, there is the possibility that bed supply and the financial motivation to fill these beds may be driving NICU admissions in this cohort. Certainly, the notion that bed supply (or lack thereof) is a significant factor in neonatal care is not entirely new. Profit et al investigated the association of NICU census and likelihood of discharge to home and found that discharge of moderately preterm infants was less likely when unit census was low.6Profit J. McCormick M.C. Escobar G.J. Richardson D.K. Zheng Z. Coleman-Phox K. et al.Neonatal intensive care unit census influences discharge of moderately preterm infants.Pediatrics. 2007; 119: 314-319Crossref PubMed Scopus (42) Google Scholar Both findings—increased admissions with more bed space availability and decreased discharges with lower unit census—call into question if NICU care use is driven strictly by clinical need or whether there may also be financial motivations impacting NICU admissions and discharges. We do acknowledge that this cynical perspective should be tempered by the possibility that clinical practice by neonatologists and general pediatricians may adapt to the availability of increased NICU services. For instance, in regions where intensive care is readily available, the skill set of general pediatricians to care for late preterm and even early term infants with issues such as respiratory and feeding immaturity may narrow over time as neonatologists assume care of these infants. Furthermore, as NICU bed supply increases for larger infants, there may be a perception among both providers and families that this higher level of care is safer and more appropriate. Thus far, there is little evidence to demonstrate that NICU care for these larger infants leads to better outcomes. Additional studies are needed to better understand how the care of these larger infants varies between NICUs and nurseries, and whether there are differences in both short-term and long-term outcomes such as rehospitalizations, growth, and development. Harrison et al have hinted at potentially unsavory aspects of NICU care, but we need additional studies to evaluate the clinical variables of these larger infants admitted to the NICU to comprehensively evaluate this association between bed supply and NICU admissions and determine if intensive care was, in fact, indicated. Finally, future studies must also consider the social, psychological, opportunity, and financial cost to families of having infants more often admitted to the NICU with increased bed availability, considering issues such as parental–infant separation and potential breastfeeding disruption, as well as the long-term challenges that persist beyond the neonatal period.7Lakshmanan A. Agni M. Lieu T. Fleegler E. Kipke M. Friedlich P.S. et al.The impact of preterm birth <37 weeks on parents and families: a cross-sectional study in the 2 years after discharge from the neonatal intensive care unit.Health Qual Life Outcomes. 2017; 15: 38Crossref PubMed Scopus (61) Google Scholar Regional variation in neonatal care results in challenges for infants, families, clinicians, and researchers alike. Acknowledgement of these variable practices is an important step in continuing to rigorously evaluate the need for and use of NICU care among infants of varying birthweights and gestational ages so that resources can be allocated efficiently and effectively to provide high-quality and consistent care to our most medically fragile patients. Regional Variation in Neonatal Intensive Care Admissions and the Relationship to Bed SupplyThe Journal of PediatricsVol. 192PreviewTo characterize geographic variation in neonatal intensive care unit (NICU) admission rates across the entire birth cohort and evaluate the relationship between regional bed supply and NICU admission rates. Full-Text PDF