WHAT'S KNOWN ON THIS SUBJECT: Data suggest that delivery at high-volume, high-technology hospitals reduces neonatal mortality. No study has examined other complications or compared the effects in multiple states by using a study design to control for unmeasured differences in case mix. WHAT THIS STUDY ADDS:The survival benefit to delivering at a high-level NICU between 1995 and 2005 is larger than previously reported and varies between states. The survival benefits affect both extremely and moderately preterm infants. Complication rates were similar between hospital types. abstract BACKGROUND: Because greater percentages of women deliver at hospitals without high-level NICUs, there is little information on the effect of delivery hospital on the outcomes of premature infants in the past 2 decades, or how these effects differ across states with different perinatal regionalization systems. METHODS:A retrospective population-based cohort study was constructed of all hospital-based deliveries in Pennsylvania and California between 1995 and 2005 and Missouri between 1995 and 2003 with a gestational age between 23 and 37 weeks (N = 1 328 132). The effect of delivery at a high-level NICU on in-hospital death and 5 complications of premature birth was calculated by using an instrumental variables approach to control for measured and unmeasured differences between hospitals.RESULTS: Infants who were delivered at a high-level NICU had significantly fewer in-hospital deaths in Pennsylvania (7.8 fewer deaths/1000 deliveries, 95% confidence interval [CI] 4.1-11.5), California (2.7 fewer deaths/1000 deliveries, 95% CI 0.9-4.5), and Missouri (12.6 fewer deaths/1000 deliveries, 95% CI 2.6-22.6). Deliveries at high-level NICUs had similar rates of most complications, with the exception of lower bronchopulmonary dysplasia rates at Missouri high-level NICUs (9.5 fewer cases/1000 deliveries, 95% CI 0.7-18.4) and higher infection rates at high-level NICUs in Pennsylvania and California. The association between delivery hospital, in-hospital mortality, and complications differed across the 3 states.CONCLUSIONS: There is benefit to neonatal outcomes when high-risk infants are delivered at high-level NICUs that is larger than previously reported, although the effects differ between states, which may be attributable to different methods of regionalization. Pediatrics
Objective To define the association between large-scale obstetric unit closures and relative changes in maternal and neonatal outcomes. Data Sources/Study Setting Birth and death certificates were linked to maternal and neonatal hospital discharge records for all births between 1/1/1995 and 6/30/2005 in Philadelphia, which experienced the closure of 9 of 19 obstetric units between 1997 and 2005, and five surrounding counties and eight urban counties that did not experience a similar reduction in obstetric units. Design A before-and-after study design with an untreated control group compared changes in perinatal outcomes in Philadelphia to five surrounding control counties and eight urban control counties after controlling for casemix differences and secular trends (N=3,140,782). Results Relative to the pre-closure years, the difference in neonatal mortality (odds ratio (OR) 1.49, 95% CI 1.12–2.00) and all perinatal mortality (OR 1.53, 95% CI 1.14–2.04) increased for Philadelphia residents compared to both control groups between 1997 and 1999. After 2000, there was no statistically significant change in any outcome in Philadelphia county compared to the pre-closure epoch. Conclusions Obstetric unit closures were initially associated with adverse changes in perinatal outcomes, but these outcomes ameliorated over time.
The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.
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