Dartmouth study questions overuse of NICUs for babies of normal birth weight

Nearly half of all newborns admitted to U.S. neonatal intensive care units (NICUs) are of normal birth weight, and a new study out of Dartmouth University links the increase to the robust expansion of NICUs over the last two decades.

According to a new report from The Dartmouth Atlas of Neonatal Intensive Care, the supply of NICU beds grew 65% between 1995 and 2013, and the number of neonatologists grew 75% during this same time period.

However, the number of newborns has remained stable.

The results of the study raise questions about whether the NICU boom is being driven by medical need or by competition among hospitals for newborns, officials said during a call with the press this week. NICUs are, in fact, high-margin money makers for hospitals.

“We fail to find an association of newborn risk with neonatal intensive care regions with higher numbers of NICU beds or neonatal clinicians per newborn. It is a concern that the location of such a valuable medical resource bears no relation to the needs of its targeted population,” David Goodman, M.D., professor of pediatrics and health policy in the Geisel School of Medicine at Dartmouth, said on a call with press.

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Thirty years ago, the most common reason newborns were admitted to the NICU was low birth weight. But in 2017, normal birth weight babies accounted for 48% of NICU admissions.

In addition, 15% of very low birth weight babies—less than 3.3 pounds—do not receive care in level 3 or 4 NICUs despite evidence showing fewer deaths and complications are associated with these more advanced NICUs.

Researchers looked at neonatal care across large populations using data from the National Center for Health Statistics, Texas Medicaid and Anthem Blue Cross and Blue Shield. And what the data revealed is that NICU care varied greatly across regions and hospitals, but the outcome of that care was not associated with any increase or decrease in patient readmittance.

And in fact, babies unnecessarily exposed to the ICU are susceptible to possible adverse effects of a hospital setting designed primarily for critical care, the report states.

Some of the possible adverse effects for unnecessary admittance into the NICU include bright lights and noise, disrupting the sleep patterns and neurodevelopment of newborns. Also, interactions between newborn and mother are interrupted, impairing bonding and breastfeeding. In addition, hospital-acquired infections, antibiotic use and the possibility of errors in medication dosing are more likely to occur. Finally, normal weight babies can keep premature newborns from being transferred back to a hospital closer to their home.

Looking at breakdowns by state, regions with low admission rates to NICUs included Richmond, Virginia, with 1.6% of normal weight babies; Laredo, Texas, 1.7%; Valdosta, Georgia, 1.7%; Roanoke, Virginia, 1.8%; and Corpus Christi, Texas, 1.8%. Regions with the highest rates included Newark, Delaware, 9.2%; Alexandria, Louisiana, 9%; El Paso, Texas, 8.9%; Stony Brook, New York, 8.3%; and Staten Island, New York, 8.1%.

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Goodman noted the number of days that infants with very low birth weight received special care differed by more than 40% based on region. For example, in El Paso, the number of adjusted special care days was on average 48 per newborn, while in Austin, it was almost 70 days. Variation was even greater across the 50 largest hospitals.

“Today there is little information available about the quality and outcomes of the care that is being provided. This is in sharp contrast to the Medicare population where measures about quality and patient experiences are routinely reported for most hospitals,” he concluded.

When asked by FierceHealthcare what comes next, Goodman responded: "Our priority is to connect the patterns of care with newborn outcomes. These studies will better define the magnitude of under and over use."