New report finds disturbing variation in neonatal intensive care

Since the 1960s, neonatal intensive care units (NICUs) have provided vital, often lifesaving, treatments for ill or premature babies. The number of NICU beds has grown substantially over the past few decades, ostensibly to provide needed care for seriously ill infants. However, little is known about how NICU resources are being allocated across the country. Does the supply of NICU beds correspond to the need for intensive care? Or are some infants being placed in the NICU when less intensive care would be safer? 

A new report from the Dartmouth Institute examined rates of NICU admissions for infants of various birth weights across the country. They found that most very low-weight infants are being admitted to the NICU regardless of geography, but for infants of moderately low birth weight or normal birth weight, there is wide regional variation in NICU admission rates. For example, 1.6% of newborns of normal weight in Richmond, VA were admitted to the NICU, but in El Paso, TX, 8.9% of these infants were admitted. Overall, almost half of all newborns admitted to NICUs in the U.S. are of normal birth weight, the Dartmouth report found. At the same time, nearly 15% of very low birth weight infants are not getting the NICU care they need. 

Source: Goodman DC, Little GA, Harrison WN, Moen A, Mowitz ME, Ganduglia Cazaban C, Bron- ner KK and Doherty JR (Eds.). The Dartmouth Atlas of Neonatal Intensive Care. Lebanon, NH: The Dartmouth Institute of Health Policy & Clinical Practice, 2019.

What’s the problem with infants of moderately low or normal birth weight being placed in the NICU? One would think that intensive care would be safer for all infants. However, the NICU also exposes newborns to the risk of overtreatment and hospital-acquired infection, and can disrupt their sleep and maternal bonding. For very sick infants, the benefits of the NICU outweigh the risks, but it’s not clear that healthier infants benefit from being in the NICU — and they may in fact be harmed by it.

Given the potential risks, why are so many infants being admitted to the NICU unnecessarily? The authors of the Dartmouth report point out that the supply of NICU beds increased by 69% nationwide from 1995-2013, and the number of neonatologists per live births has increased as well. However, this increase in resources does not appear related to the level of need in each region. In 2013, the number of NICU beds per newborn was unrelated to the region’s c-section rate or low-weight birth rate.

Variation in NICU admissions likely has more to do with financial incentives and institutional culture than medical need. NICU services are highly profitable for hospitals, giving hospitals incentives to build and expand their NICUs. Once these units are built, there is even more pressure to keep the NICU beds full, which may lead to healthier infants being placed in the NICU. Doctors may not be aware of the impact of financial incentives, but the abundance of NICU beds (as with the oversupply of other medical services) can lead to patterns of overuse within the institution. In other words, “It’s there, so we might as well use it.”

In a perfect world, all infants would be placed in the hospital newborn unit most appropriate for their health status. Unfortunately, the Dartmouth report reveals that there is significant variation in NICU admissions that appears unrelated to newborn health. While some infants of very low birth weight are not getting the NICU care they need, many other infants of normal birth weight are being placed in the NICU unnecessarily, at an enormous financial cost to the health care system. As other clinicians have pointed out, the financial resources spent on filling NICU beds could be used to help seriously ill infants and their parents after they leave the NICU, services that are crucial but often poorly reimbursed. This research from the Dartmouth Institute provides a first step toward reducing overuse and underuse in newborn care.