Premature babies need to be born in high-level units

By Piriya Mahendra

The survival benefit of delivering at a high-level neonatal intensive care unit (NICU) is larger than previously thought, a study shows.

Infants with a gestational age between 23 and 37 weeks who were delivered at a high-level NICU had significantly fewer in-hospital deaths than those who were not in three states across the USA, but had similar rates of complications.

"These benefits vary between states, suggesting that the effect of delivery hospital may depend on the organization of perinatal services or the types of populations served," comment Scott Lorch (Center for Outcomes Research, Philadelphia, Pennsylvania, USA) and co-authors in Pediatrics.

They found that there was a significantly lower in-hospital mortality rate in infants born at a high-level NICU in Pennsylvania (7.8 fewer deaths per 1000 deliveries), California (2.7 fewer deaths), and Missouri (12.6 fewer deaths) than in infants who were not.

After adjusting for measured and unmeasured case mix differences between hospital types, delivering at a high-level NICU was associated with significantly lower in-hospital mortality rates, at risk ratios of 0.35, 0.82, and 0.50 for Pennsylvania, California, and Missouri, respectively, compared with delivering at an NICU that was not high level.

There was a similar rate of complications between babies born at high-level NICUs and those who were not. However, babies born at a high-level NICU in Missouri had 9.5 fewer cases per 1000 deliveries than those born at other delivery hospitals, whereas there were no significant differences for those born in Pennsylvania and California.

The authors say that regardless of geographic region, there is a "continued survival benefit" to giving birth to premature infants at high-level NICUs. This effect is much larger than that shown in previous studies, they add.

"Differences in regionalization legislation or financial incentives to hospitals may change which hospitals build a low- or high-level NICU," remark Lorch et al.

They conclude: "Assessments of perinatal policies that only use variables available in administrative databases may not adequately adjust for actual case mix differences between hospitals."

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