Some hospitals are more likely than others to help vulnerable newborns survive. The question is why.
A trio of scientists—including two alumni of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program—published an article that sheds new light on the question. The authors reviewed existing medical literature over the last 20 years to take a closer look at the methods used to compare the quality of care at neonatal intensive care units (NICUs) in hospitals across the country.
They summarize their findings and make recommendations about how to improve cross-hospital comparisons in a new article published in a special supplement to Pediatrics, the official journal of the American Academy of Pediatrics. It was published online on March 1.
“It is more essential than ever to help patients, the public, providers and payers understand what leads to differences in survival for all patients, including newborns,” said Matthew Davis, MD, MAPP, a co-author of the study who is an associate professor of pediatrics, internal medicine and public policy at the University of Michigan and an RWJF Clinical Scholar alumnus (1998-2000). “Many researchers have proposed tools since the early 1990s to help figure out why mortality differs in newborn intensive care settings. But we found, across 10 tools, that there is not a single factor that all of the researchers agree should be included. That means that there are still major unanswered questions about what care is best for the sickest newborn babies.”
“These tools, called risk adjustment scores, help us understand that there’s something different about the care being delivered at hospitals,” added Stephen Patrick, MD, MPH, MSc, a fellow in the University of Michigan’s Division of Neonatal-Perinatal Medicine, an alumnus of the RWJF Clinical Scholars program (2010-2012), and the study’s lead author. “Better understanding these differences can help us improve care, limit deviation from evidence-based practice, and hopefully improve newborn outcomes.”
Comparing the quality of care in NICUs is tricky, Patrick said. Some hospitals tend to treat higher-risk patients and, as a result, are more likely to have higher infant mortality rates. As a result, devising a scorecard based solely on outcomes like infant mortality will not accurately reflect the quality of care delivered at hospitals or offer meaningful clues about how to improve care.
To solve the problem, researchers have devised various methods over the last two decades to adjust for patient risk. These include a variety of scorecards that take into account factors such as gestational age, newborn birth weight, and the presence of other medical conditions at the time of birth.
The scorecards, however, vary greatly.
Some, for example, take as many as 28 factors into account, while others consider as few as six. Some take into account factors like birth defects, while others don’t. The timing also differs; some consider the status of newborns 24 hours after admission, while others do so at the time of discharge.
All have strengths and weaknesses, according to the study. For more meaningful comparisons, the authors write that “risk adjustment” methods should include a description of the population at risk, take birth defects into account, and consider the hospital environment as well.
Risk-adjustment methods should also adapt to reflect changes in the needs and circumstances of the patient population, the authors add, noting that innovations such as surfactant—a substance used to protect lung tissue—alters the underlying risk of mortality.
“Continuing to develop and enhance rigorous means of risk adjustment in the NICU is critical to improving care delivered to neonates, by facilitating meaningful comparisons in quality improvement,” the authors conclude.
And that is precisely what the authors intend to do. One of his next projects, Patrick said, is developing a new tool to adjust for patient risk to help researchers, hospital administrators, and others better measure the quality of neonatal care—and ultimately improve survival of the most vulnerable newborns.