Dartmouth team finds uneven relationship between newborn intensive care and death rates

May 15, 2002

Hanover, NH -- The prevailing wisdom that more physician specialists and hospital specialty services are always better for patients is challenged by Dartmouth Medical School researchers who studied regional differences in newborn intensive care.

Their study, published May 16 in The New England Journal of Medicine, documents a wide regional disparity in the availability of newborn specialists and intensive care nursery beds that correlates poorly with improved survival. It lays the groundwork for reassessing the allocation of resources to improve newborn health and prevent disease and death, and raises questions about the continued growth of specialty medical services in the United States.

The advent of neonatal intensive care services--the neonatologists who care for premature and sick newborns and the intensive care nurseries where they are hospitalized--has dramatically improved the outlook for infants once considered too tiny or ill to survive. The growth in neonatal intensive care, driven by technological and clinical success over the past three decades, continues unabated, while its distribution across the country is more varied than other medical care resources.

Now health analysts and planners are beginning to reassess the ramifications of this growth in medical resources. In particular, they ask: are neonatal resources located where the sick babies are; does a greater supply translate into better outcomes for newborns; will further growth in supply continue to be beneficial?

The answers so far, says David Goodman, MD, associate professor of pediatrics, who led the DMS team, paint a disturbing picture of the landscape of neonatal intensive care. "Supply of neonatologists and intensive care beds is almost idiosyncratic in the way they are located; greater numbers are not found in the regions with more high risk newborns. A few regions of the country appear to be underserved in neonatologists, in that neonatal mortality rates are worse in the areas of very lowest supply. However, beyond the numbers found in the low supply areas, there are no further benefits of more neonatologists."

Goodman and his colleagues hypothesize that the "law of diminishing returns" applies to health care. "There comes a point," he says, " when adding more physicians can't lead to any further gains in outcomes." In the case of neonatal care, the fundamental determinant of neonatal outcomes is whether a baby is born premature, a factor that neonatal specialists do not directly influence. And once a sick baby is born, survival may be more related to organization of existing resources and their effective application rather than the sheer quantity of physicians or other resources, Goodman explains.

The team studied the almost 3.9 million infants born in 1995 with a birth weight of at least 500 grams (1.1 pound). The overall mortality rate (measured by death within the first 27 days of life) was 3.4 per 1000 live births. Regions in the United States were grouped based upon the supply of neonatologists per newborn--very low, low, medium, high and very high. After adjusting for factors associated with greater risk of death, such as birth weight or prenatal care, investigators found no difference in the mortality once the supply of neonatologists exceeded the "low" supply category.

The death rate was 7 percent less in regions with 4.3 neonatologists per 10,000 births than in those with 2.7 neonatologists per 10,000, but further increases in neonatologists made no difference. The low supply regions--with 4.3 neonatologists/10,000 births--had the same death rate as the highest supply regions--those with 11.6/neonatolgoists/10,000 births. The research team also looked at the supply of neonatal intensive care beds and found no reduction in mortality as the number of beds increased. The article's co-authors, who include neonatologists, epidemiologists and statisticians, are: Elliott S. Fisher, MD, MPH; George A. Little, MD; Therese A. Stukel, PhD; and Chiang-Hua Chang, MS, and Kenneth S. Schoendorf, MD. The research was funded by the Robert Wood Johnson Foundation.

"The saga of neonatology is emblematic of how a market driven health care system with inadequate public planning produced too much of a good thing," writes Kevin Grumbach of the University of California, San Francisco, in an editorial for the issue. Noting the importance of the study, he concludes that it "underscores the need for a more critical appraisal of the distribution, costs and outcomes of existing specialty services before the supply of expensive specialists and intensive care units is further expanded." Beyond neonatal mortality, whether higher numbers of physicians and intensive care beds improve newborn outcomes remains unknown. It is possible, for example, that more neonatologists could lead to faster illness resolution, while not affecting the chance of death. "The other possibility," Goodman suggests, "is that with more neonatologists or more beds, babies who would otherwise be cared for by their mothers on obstetrical units are instead admitted to intensive care units and receive more diagnostic and therapeutic interventions. Does this occur? If so, is that good or not? These are important questions for future research."

An intriguing phenomenon is that the growth of neonatal intensive care, like most specialty care, usually occurs without any explicit public planning, through private planning or institutional interest. "Strong market currents are shaping the care of our most vulnerable patients--newborns--at the beginning of life; these market forces are not currently balanced by public accountability," Goodman says.

Economic implications also make it important to determine if one is helping the right populations with the right resources, he continues. "Neonatologists and neonatal intensive care beds are expensive resources at the same time that the United States has one of the highest rates of unintended pregnancies and low birth weight of any industrialized nation." The Dartmouth study builds on earlier work documenting the geographic disparities in the neonatal workforce. The team used 1996 American Medical Association and American Osteopathic Association physician master files, and 1998 and 1999 surveys of all US neonatal intensive care units and neonatologists, as well as 1995 US vital records.
For more information, contact David Goodman: David.C.Goodman@Dartmouth.edu.

DMS news is on the web at www.dartmouth.edu/dms/news.

The Geisel School of Medicine at Dartmouth

Related Health Care Articles from Brightsurf:

Study evaluates new World Health Organization Labor Care Guide for maternity care providers
The World Health Organization developed the new Labor Care Guide to support clinicians in providing good quality, women-centered care during labor and childbirth.

Six ways primary care "medical homes" are lowering health care spending
New analysis of 394 U.S. primary care practices identifies the aspects of care delivery that are associated with lower health care spending and lower utilization of emergency care and hospital admissions.

Modifiable health risks linked to more than $730 billion in US health care costs
Modifiable health risks, such as obesity, high blood pressure, and smoking, were linked to over $730 billion in health care spending in the US in 2016, according to a study published in The Lancet Public Health.

Spending on primary care vs. other US health care expenditures
National health care survey data were used to assess the amount of money spent on primary care relative to other areas of health care spending in the US from 2002 to 2016.

MU Health Care neurologist publishes guidance related to COVID-19 and stroke care
A University of Missouri Health Care neurologist has published more than 40 new recommendations for evaluating and treating stroke patients based on international research examining the link between stroke and novel coronavirus (COVID-19).

Large federal program aimed at providing better health care underfunds primary care
Despite a mandate to help patients make better-informed health care decisions, a ten-year research program established under the Affordable Care Act has funded a relatively small number of studies that examine primary care, the setting where the majority of patients in the US receive treatment.

International medical graduates care for Medicare patients with greater health care needs
A study by a Massachusetts General Hospital research team indicates that internal medicine physicians who are graduates of medical schools outside the US care for Medicare patients with more complex medical needs than those cared for by graduates of American medical schools.

The Lancet Global Health: Improved access to care not sufficient to improve health, as epidemic of poor quality care revealed
Of the 8.6 million deaths from conditions treatable by health care, poor-quality care is responsible for an estimated 5 million deaths per year -- more than deaths due to insufficient access to care (3.6 million) .

Under Affordable Care Act, Americans have had more preventive care for heart health
By reducing out-of-pocket costs for preventive treatment, the Affordable Care Act appears to have encouraged more people to have health screenings related to their cardiovascular health.

High-deductible health care plans curb both cost and usage, including preventive care
A team of researchers based at IUPUI has conducted the first systematic review of studies examining the relationship between high-deductible health care plans and the use of health care services.

Read More: Health Care News and Health Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.